John C. Bowen

Carcinoma of the ampulla of vater

Thirty-five consecutive cases of adenocarcinoma of the ampulla of Vater seen over the past 36 years were reviewed. The introduction of new diagnostic techniques over the course of this study improved the accuracy of preoperative diagnosis but did not lead to earlier diagnosis. The surgical resectability rate was 88%, and 53% of postoperative survivors were free of disease at 5 years. Of the 14 patients with metastases to regional lymph nodes, 27% survived disease-free for 5 years. Surgical mortality was 25% for the entire series but has been reduced to 6.6% over the past decade. Surgical mortality was primarily due to leakage of the pancreaticojejunostomy; the risk of pancreaticojejunostomy leak correlated inversely with the degree of chronic pancreatitis in the pancreatic remnant. In 35% of resected cases, a benign adenomatous component was contained within the cancer of the ampulla of Vater. Cure rates are good for this lesion. The most important factor in maximizing cure rate is careful attention to the technical details of pancreaticojejunostomy in order to minimize surgical mortality. Benign adenomas appear to be a frequent precursor of carcinoma of the ampulla of Vater.

Sites of recurrence and long-term results of redo surgery.

OBJECTIVE The authors determined whether carotid endarterectomy in patients with recurrent stenosis could provide durable stroke prevention with acceptable perioperative risk. SUMMARY BACKGROUND DATA Balloon angioplasty and stenting are being advocated for recurrent stenosis because of the presumption that reoperation is unsafe with poor results. METHODS The authors retrospectively reviewed their experience with 67 patients undergoing 74 operations for recurrent stenosis in a recent 11-year period. This represented 8.4% of 883 endarterectomies performed during the same period. RESULTS At original operation, 55% had primary closure and 45% were patched. Reoperation was performed for amaurosis fugax and transient ischemic attack (45%), post-stroke (7%), global ischemia (10%), and asymptomatic severe occlusive disease (35%). Four patients (6%) undergoing simultaneous cardiac procedures were excluded from further analysis. Mean duration between primary and first redo operation was 78 months (range, 1-240 months). The 30-day combined mortality and stroke morbidity was 2.8%, evenly divided with 1.4% stroke and 1.4% mortality rates. Recurrent disease occurred predominantly (69%) in the previous endarterectomy site. Follow-up ranged from 1 to 162 months (mean, 48.2). Seventeen deaths occurred, of which 10 (59%) were cardiac. Two late ipsilateral neurologic events and four late contralateral events occurred. Two patients required third ipsilateral reoperation. Life-table analysis shows the ipsilateral stroke-free rate at 5 years to be 93.6% CONCLUSIONS Recurrent stenosis occurs either proximal to or in the previous endarterectomy site in the majority of patients. Recurrent stenosis can be treated surgically with low morbidity and mortality and durable long-term stroke prevention. The presumption that results of redo carotid surgery are poor is disproved.

Hemodynamic response to naloxone during live Escherichia coli sepsis in splenectomized dogs.

This study was designed to investigate the concept that endogenous opioids are involved in the pathogenesis of septic shock. Infusion of live Escherichia coli (1.0-1.6 X 10(10) organisms/kg) in splenectomized dogs induced profound hypotension (p less than 0.001), peripheral vasodilatation (p less than 0.001), and metabolic acidosis (p less than 0.05) with maintenance of cardiac index as compared to control splenectomized dogs. Treatment with naloxone (3 mg/kg bolus and 2 mg/kg/hr infusion for 2.5 hours), a specific opiate antagonist, during septic shock attenuated the hypotension (p less than 0.002) and systemic acidosis (p less than 0.02) without altering cardiac index or total peripheral resistance. These experimental results indicate that naloxone may be of therapeutic value in the management of the early vasodilatory stage of septicemia.

Stress ulcers during live Escherichia coli sepsis. The role of acid and bile.

This study was designed to define the conditions that will consistently produce stress ulcers following the systemic infusion of live E. coli (1.0–1.6 X 1010 organisms/kg/hr). Using gold-filled oxygen microelectrodes and the in vivo gastric chamber model in dogs, the authors found that the intracellular oxygen tension of the superficial gastric epithelium declined during sepsis despite maintenance of total gastric blood flow. This hypoxia persisted for the three-hour experiment when normal saline bathed the gastric surface (n = 6). Adding 1-mM taurocholate (Tc) (n = 6) or 80-mM hydrochloric acid (HCI) (n = 6) to the gastric chamber improved the cellular hypoxia induced by sepsis, and no ulcers were produced. However, addition of physiologic concentrations of bile in acid (1-mM Tc in 80-mM HCI) produced widespread ulceration of the mucosa within 30 minutes in nine of ten dogs. These experiments demonstrate that epithelial hypoxia induced by sepsis predisposes the gastric mucosa to ulcerate in the presence of physiologic concentrations of topical acid and bile.

Increased Oxyhemoglobin Affinity After Transfusion of Stored Blood: Evidence for Circulatory Compensation

The effect of change in red cell 2,3-diphosphoglycerate concentration after transfusion of ACD stored blood on arteriovenous oxygen content difference, arteriovenous oxygen tension difference and oxygen consumption was assessed in 15 injured patients in Vietnam. A significant increase in the arteriovenous oxygen tension difference and oxygen consumption was observed at the time of low 2,3-DPG. Change in 2,3-DPG did not correlate, however, with change in either arteriovenous oxygen content difference or venous PO(2). This study suggests that alterations in oxyhemoglobin affinity are effectively compensated, possibly by opening capillaries to increase blood flow to tissues, by reducing the capillary-tissue oxygen gradient to maintain the rate of tissue oxygen extraction, or by increasing cardiac output.

2047 The influence of young age and positive family history on local recurrence after three treatment strategies for ductal carcinoma in situ

Purpose: Three recent studies have investigated the influence of a positive family history (+FH) of breast cancer on the prognosis of DCIS patients treated by conservafive surgery end radiation therapy (CS+RT), with two studies showing a higher risk of locoregional relapse (LRR) in these patients (pts) and another showing no significant difference. Since three treatment strategies have been used for DCIS at our institotion, we evaluated the influence of +FH and young age on outcome by treatment method.