Deron J. Tessier

Clinical features and management of splenic artery pseudoaneurysm: case series and cumulative review of literature

INTRODUCTION Splenic artery pseudoaneurysm is uncommon. We report our institutions recent 18-year experience with these aneurysms and review the literature. METHODS We reviewed the records for 37 patients with visceral artery pseudoaneurysm evaluated at our institution from 1980 to 1998. From this group we found only 10 patients (27%) with splenic artery pseudoaneurysm. We also reviewed 147 cases of splenic artery pseudoaneurysm reported in the English literature. RESULTS In this series of 10 patients, 5 were men. Mean age was 51.2 years (range, 35-78 years). Causes of aneurysm included chronic pancreatitis in 4 patients, trauma in 2 patients, iatrogenic cause in 1 patient, and unknown cause in 3. The most common symptom was bleeding in 7 patients and abdominal or flank pain in 5 patients; 2 patients had no symptoms. Aneurysm diameter was known for four pseudoaneurysms, and ranged from 0.3 to 3 cm (mean, 1.7 cm). Splenectomy and distal pancreatectomy were performed in 4 patients, splenectomy alone in 2 patients, endovascular transcatheter embolization in 2 patients, and simple ligation in 1 patient. One patient with a ruptured pseudoaneurysm died before any intervention could be performed; there were no postoperative deaths. Follow-up data were available for 7 patients, with a mean of 46.3 months (range, 4.5-120 months). CONCLUSIONS Splenic artery pseudoaneurysm is rare and usually is a complication of pancreatitis or trauma. Average aneurysm diameter in our series of 10 patients was smaller than previously reported (1.7 cm vs 5.0 cm). Although conservative management has produced excellent results in some reports, from our experience and the literature, we recommend repair of all splenic artery pseudoaneurysms.

Complicated Diverticulitis: Is It Time to Rethink the Rules?

Introduction:Much of our knowledge and treatment of complicated diverticulitis (CD) are based on outdated literature reporting mortality rates of 10%. Practice parameters recommend elective resection after 2 episodes of diverticulitis to reduce morbidity and mortality. The aim of this study is to update our understanding of the morbidity, mortality, characteristics, and outcomes of CD. Methods:Three hundred thirty-seven patients hospitalized for CD were retrospectively analyzed. Characteristics and outcomes were determined using chi-squared and Fisher exact tests. Results:Mean age of patients was 65 years. Seventy percent had one or more comorbidities. A total of 46.6% had a history of at least one prior diverticulitis episode, whereas 53.4% presented with CD as their first episode. Overall mortality rate was 6.5% (86.4% associated with perforation, 9.5% anastomotic leak, 4.5% patient managed nonoperatively). A total of 89.5% of the perforation patients who died had no history of diverticulitis. Steroid use was significantly associated with perforation rates as well as mortality (P< 0.001 and P = 0.002). Comorbidities such as diabetes, collagen–vascular disease, and immune system compromise were also highly associated with death (P = 0.006, P = 0.009, and P = 0.003, respectively). Overall morbidity was 41.4%. Older age, gender, steroids, comorbidities, and perforation were significantly associated with morbidity. Conclusion:Today, mortality from CD excluding perforation is reduced compared with past data. This, coupled with the fact that the majority of these patients presented with CD as their first episode, calls into question the current practice of elective resection as a stratagem for reducing mortality. Immunocompromised patients may benefit from early resection. New prospective data is needed to redefine target groups for prophylactic resection.

Laparoscopic Adrenalectomy for Pheochromocytoma

OBJECTIVE To determine the safety and results of laparoscopic resection of benign pheochromocytomas. PATIENTS AND METHODS We retrospectively reviewed the medical charts of all patients who underwent laparoscopic adrenalectomy for benign pheochromocytomas at all 3 Mayo Clinic sites between January 1, 1992, and December 31, 2001. Demographics, comorbidities, clinical presentation, imaging studies, biochemical findings, operative intervention, and outcome were examined. Long-term follow-up was obtained via chart review and/or by direct telephone contact with the patient or a relative. RESULTS Twenty-four women and 23 men with a mean age of 53.1 years (range, 16-81 years) underwent attempted laparoscopic resection of pheochromocytomas. In 5 patients, the procedure was converted to open laparotomy because of bleeding (2), inadequate exposure (2), and adhesions (1). The mean tumor size was 4.3 cm. The mean operative time (181.8 vs 1405 minutes; P = .03), mean hospital stay (6.00 vs 2.64 days; P < .001), and mean blood loss (340 mL vs 80 mL; P < .001) were greater in patients who underwent open laparotomy vs those who underwent laparoscopic resection. All specimens were classified as benign. The mean follow-up was 41 months (range, 10-89 months). No patients experienced a recurrence or developed metastatic disease. CONCLUSIONS In light of surgical and anesthesia expertise, laparoscopic resection of benign pheochromocytomas is safe and effective with resultant short hospital stays. A low threshold to convert to an open procedure reduces operative times and decreases potentially serious complications. Although there have been no recurrences to date, long-term follow-up is required for all patients, especially those with hereditary forms of pheochromocytomas.

Laparoscopic gastric gastrointestinal stromal tumor resection: the mayo clinic experience.

HYPOTHESIS Laparoscopic resection of gastric gastrointestinal stromal tumors (GISTs) is safe and effective. DESIGN Retrospective medical record review. SETTING Tertiary referral center. PATIENTS Patients undergoing laparoscopic resection of gastric GISTs from April 1, 2000, to April 1, 2006. MAIN OUTCOME MEASURES Demographic data, diagnostic workup, operative technique, tumor characteristics, morbidity, mortality, and follow-up. RESULTS Thirty-three patients underwent attempted laparoscopic resection of gastric GISTs, with 31 operations completed laparoscopically. The mean patient age was 68 years (age range, 35-86 years). The female to male ratio was 18:15. Sixteen patients (49%) were asymptomatic, and their tumors were found incidentally. Of 24 patients (73%) who underwent preoperative endoscopic ultrasonography, the results of fine-needle aspiration verified the diagnosis in 13 patients (54%). The mean operative time was 124 minutes (range, 30-253 minutes). A combined endoscopic-laparoscopic approach was used in 11 patients (33%). The mean tumor size was 3.9 cm (range, 0.5-10.5 cm). Two patients (6%) underwent conversion to an open procedure. The median hospital stay duration was 3 days. The mean follow-up was 13 months (range, 3-64 months). There were no local recurrences. Three patients (9%) experienced complications, including 1 wound infection and 2 episodes of upper gastrointestinal tract bleeding. There were no mortalities. CONCLUSION Although technically demanding, the laparoscopic approach to gastric GISTs is safe and effective, resulting in a short hospital stay duration and low morbidity.

The small heat shock protein (HSP) 20 is dynamically associated with the actin cross-linking protein actinin.

BACKGROUND The heat shock-related protein (HSP) 20 is associated with actin and modulates smooth-muscle relaxation. We hypothesized that HSP20 mediates vasorelaxation via dynamic interactions with cytoskeletal proteins, such as actin, or actin binding proteins, such as alpha-actinin. METHODS Physiological responses of strips of bovine carotid artery were analyzed with a muscle bath. In other experiments, the arteries were homogenized, and imunoprecipitations were performed. Immunohistochemistry with anti-HSP20 and anti-actinin antibodies was used to determine co-localization of the two proteins. RESULTS Bovine carotid arteries contracted in response to serotonin and rapidly relaxed in response to forskolin. HSP20 co-immunoprecipitated with both actin and alpha-actinin, but not with HSP27 or paxillin. Immunostaining with HSP20 and alpha-actinin antibodies demonstrated that HSP20 and alpha-actinin co-localized. The amount of HSP20 that immunoprecipitated with alpha -actinin was markedly diminished in muscles that were treated with the vasorelaxant forskolin. CONCLUSIONS HSP20 is associated with both actin and alpha-actinin. Activation of cyclic nucleotide-dependent signaling pathways leads to increases in the phosphorylation of HSP20 and a decrease in the association of HSP20 with alpha-actinin. These data suggest that phosphorylation of HSP20 may lead to relaxation of vascular smooth muscles through a dynamic association with cytoskeletal elements.

Population-Based Incidence of Complicated Diverticular Disease of the Sigmoid Colon Based on Gender and Age

AbstractPURPOSE: The purpose of this study was to characterize the gender and age differences in patients with clinically symptomatic sigmoid diverticular disease requiring surgery. METHODS: All surgical patients hospitalized with proven diverticular disease requiring sigmoid resection from January 1988 to January 1998 were reviewed. RESULTS: A total of 934 patients requiring surgical resection for diverticular disease were admitted. There were 443 men and 491 women with an average age of 64. Forty-nine patients presented with massive rectal bleeding (males, 3.6 percent; females, 1.6 percent), 329 with chronic diverticulitis (males, 15.8 percent; females, 19.3 percent), 61 with obstructive symptoms (males, 2.7 percent; females, 3.9 percent), 148 with fistulas (males, 8.0 percent; females, 7.8 percent), 170 with perforation (male, 8.7 percent; female, 9.4 percent), 79 with abscess (males, 4.0 percent; females, 4.5 percent), 59 with stricture (males, 2.2 percent; females, 4.0 percent), and 39 with acute diverticulitis (males, 2.2 percent; females, 1.9 percent). Overall, patients younger than 50 presented more often with chronic or recurrent diverticulitis. CONCLUSIONS: Female patients present, on average, five years later than male with complications requiring surgery. Overall, men have a higher incidence of bleeding (P = 0.015), whereas women present more often with stricture and obstruction (P = 0.02). Young males present more with fistula (P = 0.03), whereas older males present with bleeding (P = 0.001). Young females present with perforation (P = 0.002), and older females present with chronic diverticulitis (P = 0.04) and stricture (P = 0.04).

Transduction of biologically active motifs of the small heat shock-related protein HSP20 leads to relaxation of vascular smooth muscle

Activation of cyclic nucleotide‐dependent signaling pathways leads to phosphorylation of the small heat shock‐related protein, HSP20, on serine 16, and relaxation of vascular smooth muscle. In this study, we used an enhanced protein transduction domain (PTD) sequence to deliver HSP20 phosphopeptide analogs into porcine coronary artery. The transduction of phosphoHSP20 analogs led to dose‐dependent relaxation of coronary artery smooth muscle. Peptides containing the protein transduction domain coupled to a random orientation of the same amino acids did not. Direct fluorescence microscopy of arterial rings incubated with fluorescein isothiocyanate (FITC)‐PTD or FITC‐PTD‐HSP20 peptides showed a diffuse peptide uptake. Mass spectrometric immunoassays (MSIAs) of smooth muscle homogenates were used to determine whether the phosphopeptide analogs affected the phosphorylation of endogenous HSP20. Treatment with the phosphodiesterase inhibitor papaverine led to a mass shift of 80 Da. However, there was no mass shift of HSP20 in muscles treated with phosphoHSP20 analogs. This suggests that the PTD‐phosphoHSP20 peptide alone is sufficient to inhibit force maintenance and likely has a direct effect on the target of phosphorylated HSP20. These results suggest that transduction of phosphopeptide analogs of HSP20 directly alters physiological responses of intact muscles. The data also support a direct role for phosphorylated HSP20 in mediating vasorelaxation.

Melanoma metastatic to the colon: case series and review of the literature with outcome analysis.

AbstractPURPOSE: Symptomatic melanoma of the colon is rare. The aim of this study was to determine the incidence, presenting signs and symptoms, and survival correlation. METHODS: A retrospective review was performed of all patients treated in Mayo Clinic facilities from 1960 to 2000 for primary and metastatic melanoma. We identified 24 patients with metastatic melanoma to the colon. RESULTS: There were 24 patients (14 males) with an average age of 60.4 years at the time of metastatic involvement. The interval time between diagnosis of the primary and metastatic disease to the colon was 7.47 years. The most common presentation was bleeding. Colonoscopy was used in 11 patients and diagnostic in 9. Eighteen patients underwent resection, and seven patients had positive nodes. The average time until death after operation was 27.5 months (range, 30 days to 65 months). Nonoperative candidates died within 7.8 months after diagnosis. One-year and five-year survival for resected patients were 37 and 21 percent, respectively. Patients with negative nodes had an average survival time of 34.7 months compared with 20.4 months in patients with positive nodes. Perforation and bowel obstruction directly correlated with poor survival, with an average life expectancy of ten months (P = 0.03). CONCLUSIONS: Metastatic melanoma of the colon is rare. Segmental resection is justified and can be successfully completed in 95 percent of patients who undergo attempted resection. Survival of less than ten months is most accurately predicted by signs and symptoms of obstruction or perforation at presentation (P = 0.03).

A surgeon’s guide to herbal supplements

The use of herbal supplements has steadily increased in the United States over the last decade. Despite the increased awareness of alternative therapies by the government and lay public, many physicians do not ask their patients about their use of these alternative medications. In addition, many physicians are unaware of the possible side effects that may occur when a patient consumes these substances. Considering a number of these supplements have been associated with adverse reactions in the perioperative period, it is important for a surgeon to understand all of the herbs a patient may be taking. The purpose of this article is to discuss the growing trend of herbal use among surgical patients and give the reader some background on the most commonly used herbs.

Causes, diagnosis, and management of duodenal obstruction after aortic surgery

While ileus is common after repair of abdominal aortic aneurysm, small bowel obstruction is uncommon and duodenal obstruction is rare. We report a case of high-grade, mechanical obstruction of the third and fourth portions of the duodenum that required operative intervention. A review of the literature is included, with emphasis on the causes, diagnosis, and management options for duodenal obstruction associated with aortic reconstructive surgery.