Albert E. Yellin

Effect of partial ileal bypass surgery on mortality and morbidity from coronary heart disease in patients with hypercholesterolemia: Report of the program on the surgical control of the hyperlipidemias (posch)

BACKGROUND AND METHODS The Program on the Surgical Control of the Hyperlipidemias (POSCH), a randomized clinical trial, was designed to test whether cholesterol lowering induced by the partial ileal bypass operation would favorably affect overall mortality or mortality due to coronary heart disease. The study population consisted of 838 patients (417 in the control group and 421 in the surgery group), both men (90.7 percent) and women, with an average age of 51 years, who had survived a first myocardial infarction. The mean follow-up period was 9.7 years. RESULTS When compared with the control group at five years, the surgery group had a total plasma cholesterol level 23.3 percent lower (4.71 +/- 0.91 vs. 6.14 +/- 0.89 mmol per liter [mean +/- SD]; P less than 0.0001), a low-density lipoprotein cholesterol level 37.7 percent lower (2.68 +/- 0.78 vs. 4.30 +/- 0.89 mmol per liter; P less than 0.0001), and a high-density lipoprotein cholesterol level 4.3 percent higher (1.08 +/- 0.26 vs. 1.04 +/- 0.25 mmol per liter; P = 0.02). Overall mortality and mortality due to coronary heart disease were reduced, but not significantly so (deaths overall [control vs. surgery], 62 vs. 49, P = 0.164; deaths due to coronary disease, 44 vs. 32, P = 0.113). The overall mortality in the surgery subgroup with an ejection fraction greater than or equal to 50 percent was 36 percent lower (control vs. surgery, 39 vs. 24; P = 0.021). The value for two end points combined--death due to coronary heart disease and confirmed nonfatal myocardial infarction--was 35 percent lower in the surgery group (125 vs. 82 events; P less than 0.001). During follow-up, 137 control-group and 52 surgery-group patients underwent coronary-artery bypass grafting (P less than 0.0001). A comparison of base-line coronary arteriograms with those obtained at 3, 5, 7, and 10 years consistently showed less disease progression in the surgery group (P less than 0.001). The most common side effect of partial ileal bypass was diarrhea; others included occasional kidney stones, gallstones, and intestinal obstruction. CONCLUSIONS Partial ileal bypass produces sustained improvement in the blood lipid patterns of patients who have had a myocardial infarction and reduces their subsequent morbidity due to coronary heart disease. The role of this procedure in the management of hypercholesterolemia remains to be determined. These results provide strong evidence supporting the beneficial effects of lipid modification in the reduction of atherosclerosis progression.

Evaluation of Penetrating Injuries of the Neck: Prospective Study of 223 Patients

Abstract. The objective of this study was to assess the role of clinical examination, angiography, color flow Doppler imaging, and other diagnostic tests in identifying injuries to the vascular or aerodigestive structures in patients with penetrating injuries to the neck. A prospective study was made of patients with penetrating neck injuries. All patients had a careful physical examination according to a written protocol. Stable patients underwent routine four-vessel angiography and color flow Doppler imaging. Esophagography and endoscopy were performed for proximity injuries. The sensitivity, specificity, and predictive values of physical examination, color flow Doppler studies, and other diagnostic tests were assessed during the evaluation of vascular and aerodigestive tract structures in the neck. Altogether 223 patients were entered in the study. After physical examination 176 patients underwent angiography and 99 of them underwent color flow Doppler imaging. Angiographic abnormalities were seen in 34 patients for an incidence of 19.3%, but only 14 (8.0%) required treatment. Color flow Doppler imaging was performed on 99 patients with a sensitivity of 91.7%, specificity 100%, positive predictive value (PPV) 100%, and negative predictive value (NPV) 99%. These values were all 100% when only injuries requiring treatment were considered. None of the 160 patients without clinical signs of vascular injury had serious vascular trauma requiring treatment (NPV 100%), although angiography in 127 showed 11 vascular lesions not requiring treatment. “Hard” signs on clinical examination (large expanding hematomas, severe active bleeding, shock not responding to fluids, diminished radial pulse, bruit) reliably predicted major vascular trauma requiring treatment. Among 34 of the 223 total patients (15.2%) admitted with “soft” signs, 8 had angiographically detected injuries, but only one required treatment. An esophagogram was performed on 98 patients because of proximity injuries (49 patients) or suspicious clinical signs (49 patients), and two of them showed esophageal perforations. None of the 167 patients without clinical signs of esophageal trauma had an esophageal injury requiring treatment. It was concluded that physical examination is reliable for identifying those patients with penetrating injuries of the neck who require vascular or esophageal diagnostic studies. Color flow Doppler imaging is a dependable alternative to angiography. An algorithm for the initial assessment of neck injuries is suggested.

Ertapenem Versus Piperacillin/Tazobactam in the Treatment of Complicated Intraabdominal Infections: Results of a Double-Blind, Randomized Comparative Phase III Trial

ObjectiveTo examine the clinical efficacy and safety of ertapenem, a novel &bgr;-lactam agent with wide activity against common pathogens encountered in intraabdominal infection. Summary Background DataErtapenem has a pharmacokinetic profile and antimicrobial spectrum that support the potential for use as a once-a-day agent for the treatment of common mixed aerobic and anaerobic infections. MethodsThis prospective, randomized, controlled, and double-blind trial was conducted to compare the safety and efficacy of ertapenem with piperacillin/tazobactam as therapy following adequate surgical management of complicated intraabdominal infections. ResultsSix hundred thirty-three patients were included in the modified intent-to-treat population, with 396 meeting all criteria for the evaluable population. Patients with a wide range of infections were enrolled; perforated or abscessed appendicitis was most common (approximately 60% in microbiologically evaluable population). A prospective, expert panel review was conducted to assess the adequacy of surgical source control in patients who were failures as a component of evaluability. For the modified intent-to-treat groups, 245 of 311 patients treated with ertapenem (79.3%) were cured, as were 232 of 304 (76.2) treated with piperacillin/tazobactam. One hundred seventy-six of 203 microbiologically evaluable patients treated with ertapenem (86.7%) were cured, as were 157 of the 193 (81.2%) treated with piperacillin/tazobactam. ConclusionsIn this study, the efficacy of ertapenem 1 g once a day was equivalent to piperacillin/tazobactam 3.375 g every 6 hours in the treatment of a range of intraabdominal infections. Ertapenem was generally well tolerated and had a similar safety and tolerability profile to piperacillin/tazobactam. A formal process for review of adequacy of source control was found to be of benefit. The results of this trial suggest that ertapenem may be a useful option that could eliminate the need for combination and/or multidosed antibiotic regimens for the empiric treatment of intraabdominal infections.

Duodenal “diverticulization” for duodenal and pancreatic injury

Abstract Duodenal “diverticulization” has been achieved in thirty-four cases of combined duodenal and pancreatic or severe duodenal or pancreatic injury. The operation consists of gastric antrectomy with end to side gastrojejunostomy, tube duodenostomy, closure of the duodenal perforation, and drainage. The combined mortality for these thirty-four cases and a previously reported series of sixteen cases is 16 per cent. Regional complications that developed after duodenal diverticulization were generally well tolerated and not lethal. All duodenal and pancreatic fistulas closed spontaneously.

Choledochal cyst in the adult.

ObjectiveThe authors examined the natural history of choledochal cysts in adults treated surgically. BackgroundAn initial diagnosis of choledochal cyst is uncommon in adults. The recommended treatment is excision, rather than bypass, to achieve effective biliary drainage and because of the risk of cancer. MethodsA retrospective study of 27 adult patients was completed to determine the frequency of anastomotic complications and the incidence of cancer. ResultsFifteen patients were treated by cyst excision, and one developed an anastomotic stricture, treated by percutaneous dilation. Eight of 11 patients treated by cyst enterostomy required additional surgery for anastomotic revision. A final patient was treated by T-tube drainage. Five of the seven patients with cancer have died at a mean of 21.6 months. ConclusionThis experience documents the high incidence of cancer (26%), and high rate of stricture after cyst enterostomy (73%). The dismal prognosis once cancer has developed warrants cyst excision, even in asymptomatic patients, including those with prior cyst enterostomies.

Results of a Randomized Trial of End-to- Side Portacaval Shunt and Distal Splenorenal Shunt in Alcoholic Liver Disease and Variceal Bleeding

Since 1976, we have compared the end-to-side portacaval shunt (PCS) with the distal splenorenal shunt (DSRS) in patients with alcoholic liver disease and recurrent variceal bleeding. Fifty-four patients were randomly assigned to receive either shunt procedure. There were 27 patients in each group and both groups were highly comparable in clinical and laboratory characteristics. Median follow-up was 31 mo in each group. Postoperative complications and operative mortality (7% after PCS, 12% after DSRS) were comparable. Spontaneous portasystemic encephalopathy developed in 32% of the patients at risk after PCS and in 39% after DSRS. Rebleeding from varices occurred in 4% of the patients after PCS and in 27% after DSRS. Cumulative survival was not significantly different between groups (5-yr survival: 31% after PCS, 43% after DSRS). We have failed to demonstrate superiority of DSRS in our patients with alcoholic liver disease with respect to postoperative encephalopathy or survival, and have experienced an unusually high rate of variceal rebleeding after DSRS.

Blunt popliteal artery trauma: One hundred consecutive injuries

An institutional experience with 100 consecutive blunt popliteal artery injuries over a 20-year period was reviewed. The overall amputation rate was 15%; however, during the past 7 years this has declined from 23% to 6%. Minimizing delay in the revascularization of ischemic limbs, routine systemic heparinization, primary arterial repair when possible, repair of popliteal venous injuries, aggressive wound debridement, and early soft tissue coverage have contributed to improved limb salvage during the 1980s.

Surgical procedures in the management of Takayasu's arteritis

Takayasus arteritis is an inflammatory arteriopathy that often progresses to obliteration of multiple large arteries. Variable results have been reported after medical and surgical management. Twenty female patients with Takayasus arteritis were treated from 1973 to 1989. Eleven (55%) patients had hypertension. Upper or lower extremity ischemia was present in 12 (60%) patients and cerebrovascular insufficiency in seven (35%). Nine patients initially managed with corticosteroids had no improvement in signs or symptoms of arterial insufficiency. Eleven patients had 16 vascular procedures for the following indications: renovascular hypertension (6), extremity ischemia (5), cerebrovascular insufficiency (2), dilation ascending aorta with aortic insufficiency (1), thoracic aortic aneurysm (1), abdominal aortic aneurysm (1). Procedures included aortorenal bypass (5), carotid-subclavian, axillary, or brachial bypass (4), aorto-carotid bypass (2), aneurysm resection (2), supra-celiac aorto-femoral bypass (1), ascending aorta/aortic valve replacement (1), and nephrectomy (1). Clinical improvement occurred in all patients. There were no operative deaths. All are alive at a mean follow-up of 5.75 years (6 months to 16 years). Revision of the initial reconstruction has been required for recurrent renovascular hypertension in one patient and extremity ischemia in another. The other nine patients remain symptomatically improved. Symptomatic Takayasus arteritis frequently requires arterial reconstruction. Symptomatic improvement and excellent long-term graft patency can be expected after arterial reconstruction.

Selective surgical therapy of the Budd-Chiari syndrome provides superior survivor rates than conservative medical management

The Budd-Chiari syndrome is an unusual form of portal hypertension caused by hepatic vein occlusion, which results in centrilobular congestion and necrosis. Its overall mortality rate exceeds 50% at 2 years, and optimal treatment remains controversial. To determine optimal therapy on the basis of clinical and angiographic data, we retrospectively analyzed 30 patients with this disease treated at the University of California, Los Angeles or the University of Southern California School of Medicine between 1955 and 1985. Twelve patients were treated conservatively with diuretics, anticoagulants, paracentesis, and/or peritoneal-venous shunt. Eighteen patients were treated by definitive surgery: side-to-side portocaval shunt (four), mesocaval shunt (four), side-to-side splenorenal shunt (one), liver transplantation (two), transatrial membranotomy (TM) (two), TM followed by inferior vena cava reconstruction (IVCR) (one), TM followed by mesocaval shunt (one) simultaneous IVCR and side-to-side portocaval shunt (one), IVCR (one), and azygousatrial shunt followed 4 years later by a splenopulmonary shunt (one). Overall the surgical group had survival rates superior to the medical group, with a 2-year survival rate of 54% for the surgical group vs. 9% for the medical group (p less than 0.089). On the basis of these data we conclude that surgical therapy is superior to medical therapy for the Budd-Chiari syndrome. However, the operation must be tailored to treat the specific anatomic and clinical abnormality. Guidelines to select the proper surgical procedure are given.

In Vitro Activities of Nontraditional Antimicrobials against Multiresistant Acinetobacter baumannii Strains Isolated in an Intensive Care Unit Outbreak

ABSTRACT Fifteen multiresistant Acinetobacter baumannii isolates from patients in intensive care units and 14 nonoutbreak strains were tested to determine in vitro activities of nontraditional antimicrobials, including cefepime, meropenem, netilmicin, azithromycin, doxycycline, rifampin, sulbactam, and trovafloxacin. The latter five drugs were further tested against four of the strains for bactericidal or bacteriostatic activity by performing kill-curve studies at 0.5, 1, 2, and 4 times their MICs. In addition, novel combinations of drugs with sulbactam were examined for synergistic interactions by using a checkerboard configuration. MICs at which 90% of the isolates tested were inhibited for antimicrobials showing activity against the multiresistant A. baumannii strains were as follows (in parentheses): doxycycline (1 μg/ml), azithromycin (4 μg/ml), netilmicin (1 μg/ml), rifampin (8 μg/ml), polymyxin (0.8 U/ml), meropenem (4 μg/ml), trovafloxacin (4 μg/ml), and sulbactam (8 μg/ml). In the kill-curve studies, azithromycin and rifampin were rapidly bactericidal while sulbactam was more slowly bactericidal. Trovafloxacin and doxycycline were bacteriostatic. None of the antimicrobials tested were bactericidal against all strains tested. The synergy studies demonstrated that the combinations of sulbactam with azithromycin, rifampin, doxycycline, or trovafloxacin were generally additive or indifferent.