F. E. Eckhauser

Cystic neuroendocrine neoplasms of the pancreas and liver.

Four cases involving cystic endocrine neoplasms of the pancreas and liver are reported. Because of their rich collateral blood supply, islet cell tumors of the pancreas, even if large in size, rarely undergo central or cystic degeneration. However, failure to appreciate that a small percentage of these neoplasms may mimic benign pancreatic pseudocysts by their clinical and radiological appearance can lead to inappropriate surgical therapy. Ultrasound, computerized tomography, and/or angiography are rarely helpful in distinguishing between benign and neoplastic cysts. The definitive diagnosis can be made with assurance only by obtaining a generous biopsy of the cyst wall or any intracystic excrescences for histologic examination. Functional cystic tumors of the pancreas or liver should be excised totally whenever possible, and efforts should be made to remove as much of the tumor mass as possible even when a curative resection cannot be accomplished. Internal drainage may be acceptable as palliation for large, unresectable tumors.

Clinical Features of Carcinoid Syndrome and the Use of Somatostatin Analogue in Its Management

A review is given on the clinical features of carcinoid syndrome including symptomatology, diagnostics, biochemistry and treatment. We have reviewed the literature on current therapy of carcinoid patients with special emphasis on the use of the somatostatin analogue SMS 20-1995. In addition, we present data on the effects of SMS 201-995 on indices of a clinical, biochemical and tumor growth. Diarrhea is abolished or significantly reduced in 75% of patients, flushing improves in 100%, wheezing in 100% with a decrease in airways resistance, and in one patient myopathy has improved. Blood serotonin is notoriously resistant to intervention and urinary 5-HIAA will decrease in 75% of causes but subsequently rebounds in 38%. Tumors, in general, continue to grow, but this may be slowed or in rare cases tumor growth is arrested. In individual instances the tumor may even infarct, leading to spontaneous cure. Tumors secreting PP, ACTH and calcitonin may be particularly resistant to treatment, whereas VIP secreting tumors appear to be sensitive.

Unusual Causes of Benign Biliary Strictures With Cholangiographic Features of Cholangiocarcinoma

Focal strictures occurring at the hepatic duct confluence, or within the common hepatic duct or common bile duct in patients without a history of prior surgery in that region or stone disease, are usually thought to represent cholangiocarcinoma until proved otherwise. However, not uncommonly, patients undergo surgical exploration for a preoperative diagnosis of cholangiocarcinoma, based on the cholangiographic appearance of the lesion, only to find histologically that the stricture was benign in nature. Despite sophisticated radiographic, endoscopic, and histologic studies, it is often impossible before laparotomy to distinguish malignant from benign strictures when they have the characteristic radiographic appearance of cholangiocarcinoma. Even at the risk of overtreating some benign cases, most agree that aggressive surgical resection is the treatment of choice, given the serious consequences resulting from a failure to diagnose and adequately treat cholangiocarcinoma. Four patients who presented to our institution between February 1991 and June 2000 underwent laparotomy for a preoperative diagnosis of biliary tract malignancy based on clinical presentation and cholangiographic findings. The final pathology report in all patients showed marked fibrosis and inflammation of the biliary duct without evidence of malignancy. A review of the patient data and the relevant literature identified benign causes of focal extrahepatic biliary strictures associated with concomitant disease processes in two of the four patients. We present these cases and discuss the benign etiologies with emphasis on the role of surgery in both diagnosis and treatment.

Endoscopy of the partitioned stomach.

Fiberoptic endoscopy is an important diagnostic modality for evaluation of the patient with upper gastrointestinal (GI) tract symptoms following gastric bypass and gastroplasty. During a 3-year period, 182 patients underwent gastric partitioning procedures and 22 patients (12%) developed upper GI symptoms requiring endoscopic evaluation. Eight patients had undergone Mason vertical banded gastroplasty, 12 patients had undergone Gomez gastroplasty, and two patients had undergone Roux-en-Y gastric bypass. In four of five patients with abdominal pain, gastritis of the proximal pouch was observed. Of the two patients with symptoms of obstruction of the proximal gastric outlet, one patient was found to have a cherry pit occluding the channel. Intraoperative endoscopy was performed in one patient who developed upper GI bleeding after Roux-en-Y gastric bypass, the pylorus was scarred and stenotic and multiple superficial ulcerations were seen in the excluded distal stomach. In eight patients with symptoms suggestive of channel stenosis, four were found to have a stenotic channel and underwent endoscopic dilation of the channel. Upper GI endoscopy was performed in eight patients with Gomez gastroplasty to confirm suspected dilatation of the channel between the upper and lower gastric pouches. Upper GI contrast studies did not estimate accurately the diameter of the channel as determined during endoscopy. No complications were observed following any of the endoscopic procedures. As the collective experience with gastric partitioning procedures increases, the need for endoscopic examinations of the upper GI tract will also increase. Endoscopists should be familiar with the altered gastric anatomy and with the spectrum of upper GI lesions that develop following these operations.

Parastomal ileal conduit hemorrhage and portal hypertension

An analysis of six cases of parastomal ileal conduit hemorrhage in patients with portal hypertension is presented. The presence of coexisting esophageal varices, documented in only one of six cases (17%), suggest preferential retrograde portal flow through mesenteric venous (as opposed to coronary-azygos) collateral channels. Venous phase mesenteric angiography offers the best diagnostic specificity and provides inferential evidence regarding overall liver blood flow. Operative therapy should be based on assessment and understanding of the splanchnic circulatory derangements which accompany intrahepatic portal obstruction.

Effects of portacaval shunt and portacaval transposition on hepatocellular and hepatic reticuloendothelial cell activity in the dog

UNLABELLED Quantitative reduction of portal blood flow following a portacaval shunt (PCS) adversely affects hepatocyte function, but does not alter HRES activity [L. P. Edgcomb , J. A. Knol , and F. E. Eckhauser . J. Surg . Res. 33: 233, 1982]. To determine whether similar changes occur after qualitative alteration of portal blood flow, portacaval transpositions (PCT) were constructed in six conditioned mongrel dogs. Estimated hepatic blood flow (EHBF) was determined scintigraphically by the rate of hepatic uptake of a 500-microCi dose of 99mTc -sulfur colloid (Tsc). Hepatic reticuloendothelial cell (RES) phagocytic (PI) and degradative (DI) indices were calculated from the half-time blood disappearance of 131I-labeled RES test lipid emulsion, and the half-time urine appearance of free 131I, respectively. Opsonic activity (OI) was determined by gelatin latex particle agglutination and normalized to control values. Hepatocellular function was assessed by serial determinations of albumin (Alb), and pyruvic and glutamic oxaloacetic transaminases (SGPT and SGOT). All studies were performed prior to and at 3, 6, and 9 weeks following PCS or PCT. CONCLUSIONS In the dog, neither PCS nor PCT adversely affected HRES activity. Hepatocellular function and OI remained unchanged following PCT but deteriorated significantly after PCS. Observed changes in hepatocyte function and OI following PCS suggest that hepatocellular integrity and serum opsonic activity may be interrelated.

Differential effects of portal diversion on hepatocyte function (HF) and hepatic reticuloendothelial cell (HRES) activity in the dog

Abstract End-to-side portocaval shunts (PCS) were constructed in six dogs to evaluate the effect of complete portal blood flow diversion on hepatocellular structure and function, hepatic reticuloendothelial (RE) activity, and serum opsonic activity (OA). RE activity remained normal after PCS despite a 40% reduction in estimated hepatic blood flow. Tissue distribution of injected colloid shifted away from liver to spleen, lung, and bone marrow. OA decreased to 40% of baseline values 6 weeks after PCS and remained low. Postshunt changes in hepatic morphology primarily affected hepatocytes and included deglycogenation and loss of rough endoplasmic reticulum. Significant changes in Kupffer cell morphology were not observed. Complete portal flow diversion in the dog caused profound alterations in hepatocellular structure and function without compromising Kupffer cell phagocytic and metabolic activity. Kupffer cells may be less dependent than hepatocytes upon hepatotrophic factors contained in portal blood. OA did not correlate with changes in vascular lipid clearance, suggesting that either phagocytosis of RES test lipid in the dog is not dependent on prior opsonization, or that the assay used was neither sensitive nor specific enough to measure a critical opsonic threshold required for effective phagocytosis.

Enterooxyntin Release from Isolated Perfused Canine Jejunum

UNLABELLED A humoral factor may mediate the intestinal phase of gastric acid secretion. An ex vivo perfused segment of canine jejunum maintained by an oxygenated asanguinous physiologic perfusate was used to test for release of an enterooxyntin (EO) in response to balloon distention at 30 mm Hg for 15 min. Gastric acid secretion in guinea pig fundic mucosa was determined indirectly by a quantitative cytochemical bioassay (CBA) of oxyntic cell hydroxyl ion production (HIP). An increase in the optical density (OD) caused by the cytochemical stain in the oxyntic cells reflects HIP, an index of acid secretion. Basal OD for segments with distention was 16.6 +/- 0.53 and for those without 15.5 +/- 0.68 (NS). Results are expressed as mean change of OD from basal (mean delta OD +/- SEM). (Table-see text) EO caused greater stimulation of HIP than gastrin or histamine. EO was heat stable. Trichloroacetic acid treatment decreased EO activity as did pronase digestion suggesting that EO is composed of one or more peptides. CONCLUSION EO, an acid secretagogue, is a humoral agent probably composed of one or more peptides and is released by small bowel distention. Mechanical distention of the small bowel may be an important mechanism for the perpetuation of gastric acid secretion. The ex vivo perfused jejunal segment in conjunction with the CBA are ideal tools with which to study mechanisms of release of EO and the mechanism of action of EO on the oxyntic cell.

Pseudolymphoma of Colon

A case of pseudolymphoma of the colon is reported. Radiographically and endoscopically the lesion could not be conclusively distinguished from malignant neoplasm, particularly lymphoma or segmental colitis, thus necessitating right hemicolectomy. Careful histological examination established the diagnosis of pseudolymphoma with pathologic features identical to the focal form of pseudolymphoma more commonly observed in the stomach.

Hepatic vascular exclusion for hepatic resection

The scope of blood loss and replacement with liver surgery is important in the final results of such surgery. Although intraoperative death from bleeding was once a significant consideration with liver resections, it is now an uncommon cause of death for elective liver operations. Nevertheless, control of blood loss remains an important issue. There is a strong correlation between blood loss in excess of 4–5 liters and postoperative complications and hospital mortality in patients undergoing liver resection [1,2]. Significant intraoperative bleeding obscures the operative field such that accidental injury to biliary structures is more likely to occur and location and control of bleeding vessels are more difficult. Large transfusion requirements frequently result in coagulopathies with additional bleeding. Hypotension and hypoperfusion associated with blood loss have negative physiologic consequences for many organ systems. There is a risk of serious viral infection correlating with the amount of blood products administered. Finally, for patients in whom liver resection is for treatment of malignancy, evidence is mounting that there is an increased rate of recurrence of malignancy when substantial blood transfusions are given in the perioperative period [3,4].