Kenneth R. Sirinek

Virulent diverticular disease in young obese men

Recent treatment of young patients (aged 40 years or less) with complicated diverticulitis prompted us to review our experience. During a 9-year period ending in December 1990, 61 of 238 patients treated for acute diverticulitis were 40 years of age or younger. The younger patients were primarily obese Hispanic males in whom the correct diagnosis was frequently missed. Younger patients more frequently required an operation on an urgent basis for complications of diverticulitis during the initial hospitalization. The most common indication for operation in young patients was perforation compared with recurrent disease for the older age group. The younger group had a sevenfold incidence of enteric fistulas complicating their acute episode of diverticulitis. Our data suggest that diverticular disease in young patients is more common and more likely to require early surgical intervention than previously noted. In addition, obesity may represent an important etiologic factor in the development of diverticular disease.

Pentagastrin stimulates in vitro growth of normal and malignant human colon epithelial cells

Five normal and four malignant human colon epithelial cultures initiated and maintained in our laboratories as well as the standardized in vitro human adenocarcinoma cell line HT-29 were plated in multiwell plates and incubated at 37 degrees C for 72 hours with either phosphate-buffered saline solution or pentagastrin (5 micrograms/ml). Pentagastrin stimulated normal cells to increase (p less than 0.05) in number by an average of 65 percent compared with saline control cells, whereas malignant cells increased an average of 59 percent compared with control cells. There was no difference in the magnitude of trophic effect between the normal and malignant cells. Further studies are indicated to elucidate the role of gastrin in either initiating, promoting, or both, the growth of carcinoma of the colon.

Laparoscopic cholecystectomy for biliary tract emergencies : State of the art

Although laparoscopic cholecystectomy is unusually safe and well tolerated in patients with routine symptomatic cholelithiasis, it can become a formidable procedure when used to manage biliary tract emergencies. Optimally, a reasoned and cautious approach and a low threshold for conversion can avoid major complications. One such emergency, acute cholecystitis, may be particularly hazardous because of the relatively common finding of severe inflammation with dense adhesions to adjacent viscera and gallbladder necrosis. Special modifications of technique may be required. Overall, urgent operation (within 72 hours) results in an acceptably low mortality (0.3%) but a somewhat higher conversion rate (16%) and longer hospital stay (3 days). Unnecessary delays may result in more adhesions and an increased level of operative difficulty. In patients who are at an especially high risk because of co-morbid disease, percutaneous cholecystostomy is an appropriate alternative strategy. Biliary pancreatitis may be associated with high mortality (9%) and has an unpredictable course. Accordingly, a multidisciplinary approach that may include both gastroenterologists and radiologists is generally advisable. Because common bile duct (CBD) stones are present in more than 20% of patients who present with biliary pancreatitis, endoscopic retrograde cholangiopancreatography (ERCP) can be used effectively on a selective basis during the preoperative or postoperative period; the preferred timing continues to be somewhat controversial. As an alternative approach, laparoscopic CBD exploration is gradually gaining wider acceptance. In eight reported series using a variety of techniques for stone extraction, major complications were infrequent (10%), and the conversion rate was low (5%). Acute suppurative cholangitis is a more fulminant problem that is best managed by expeditious ERCP with removal of all intraductal stones. Resuscitation should be continued until complete; laparoscopic cholecystectomy can follow at an appropriate interval.

Civilian Vascular Trauma of the Upper Extremity

One hundred forty-three patients with 163 upper extremity vascular injuries were reviewed. Penetrating trauma accounted for 94% of the injuries and blunt trauma for 6%. Absent pulses are not a completely reliable sign of upper extremity arterial injury. The most frequently injured upper extremity vessel is the brachial artery, followed in decreasing frequency by ulnar, radial, and axillary arterial injuries and axillary venous injuries. The most common technique of vascular repair was end-to-end anastomosis, followed by vein graft interposition. No amputations were required. Despite excellent results of vascular reconstruction, functional impairment due to associated nerve injuries was a distressingly predominant finding.

Chronic renal failure: Effect of hemodialysis on gastrointestinal hormones

Fifteen patients with chronic renal failure (serum creatinine level greater than 5 mg/dl) of long duration (more than 2 years) requiring hemodialysis were studied. Blood samples before and after 4 hours of hemodialysis were assayed for creatinine, blood urea nitrogen, potassium, calcium, glucose, insulin, gastrin, gastric inhibitory polypeptide, vasoactive intestinal polypeptide, pancreatic polypeptide, somatostatin, motilin, and neurotensin levels. Before dialysis, serum gastrin was minimally increased whereas gastric inhibitory polypeptide and pancreatic polypeptide were grossly increased compared with normal fasting values. Hemodialysis produced no changes in serum gastric inhibitory polypeptide, vasoactive intestinal polypeptide, pancreatic polypeptide, somatostatin, motilin, and neurotensin. Slight increases in serum insulin and gastrin levels may have occurred secondary to a dialysis-induced increase in the serum calcium level. The kidneys appear to be a major site of inactivation of insulin, gastrin, gastric inhibitory polypeptide, and pancreatic polypeptide. The gastrin level, although elevated in renal failure patients, may be suppressed by very high circulating levels of gastric inhibitory polypeptide.

The radiolabeled microsphere technique in gut blood flow measurement—Current practice

Measurement of blood flow to the gut has become an integral part of the physiologic study of the gastrointestinal tract. While many methods have been utilized in measuring tissue blood flow, the one most often practiced today is dependent on injection of radioactively labeled microspheres. The theoretical basis of the microsphere technique is analogous to that of the indicator-dilution method. A bolus of microspheres suspended in a suitable vehicle is injected into the left atrium or left ventricle where they mix uniformly with the oxygenated blood. They are then distributed via aortic blood flow to the capillary beds within each organ in proportion to the volume of microsphere-containing blood. Technical aspects of tissue processing, gamma energy detection, and gamma spectrum analysis are reviewed. Sources of experimental error and techniques for their reduction are also discussed.

Operations for peptic ulcer disease: paradigm lost

Over the past several decades, the pharmacologic and endoscopic treatment of peptic ulcer disease (PUD) has dramatically improved. To determine the effects of these and other changes on the operative management of PUD, we reviewed our surgical experience with gastroduodenal ulcers over the past 20 years. A computerized surgical database was used to analyze the frequencies of all operations for PUD performed in two training hospitals during four consecutive 5-year intervals beginning in 1980. Operative rates for both intractable and complicated PUD were compared with those for other general surgical procedures and operations for gastric malignancy. In the first 5-year period (1980 to 1984), a yearly average of 70 upper gastrointestinal operations were performed. This experience included 36 operations for intractability, 15 for hemorrhage, 12 for perforation, and seven for obstruction. During the same time span, 13 resections were performed annually for gastric malignancy, By the most recent 5-year interval (1994 to 1999), the total number of upper gastrointestinal operations had declined by 80% (14 cases), although the number of operations for gastric cancer had changed only slightly. Operations decreased most markedly for patients with intractability, but the prevalence of operations for bleeding, obstruction, and perforation was also decreased. We conclude that improved pharmacologic and endoscopic approaches have progressively curtailed the use of operative therapy for PUD. Elective surgery is now rarely indicated, and emergency operations are much less common. This changed paradigm poses new challenges for training and suggests different approaches for practice.

Nondiagnostic thyroid fine-needle aspiration biopsies are no longer a dilemma.

BACKGROUND Nondiagnostic fine-needle aspiration biopsy (ND-FNAB) of the thyroid leads to unnecessary thyroidectomy. The aims of this study were as follows: (1) to determine the risk of malignancy in ND-FNABs, and (2) to evaluate factors that may identify patients at risk for a ND-FNAB. METHODS A total of 241 patients who underwent FNAB and thyroidectomy were evaluated for factors associated with a ND-FNAB. RESULTS A total of 215 women and 26 men underwent FNAB and thyroidectomy. ND-FNAs occurred in 51 of 241 (21%) patients. Ultrasound guidance did not reduce the likelihood of a ND biopsy. Patients with nodules greater than 3 cm had more ND-FNAs. Twenty-one of 51 with a ND biopsy underwent a repeat FNAB. Repeat FNAB was ND in 29% of patients. There was malignant disease in 7 of 51 (14%) with a ND-FNAB. Patient age, sex, thyroid function, gland size, multiple nodules, and final pathology were not related to a ND-FNAB (P > .05). CONCLUSIONS Most patients with a ND-FNAB have benign disease and low-risk patients with a ND-FNAB on repeat FNA warrant a more conservative approach.

Truncal Vascular Injury—factors Influencing Survival

During the 10-year period ending June 1982, 219 patients were treated for 269 injuries to the major vessels of the abdominal and thoracic cavities, with 28% morbidity and 32% mortality. One hundred eighty patients (82%) had 377 associated injuries consisting primarily of damage to the small intestine (79), liver (45), and large intestine (34). Factors associated with an increased mortality included: more than three associated injuries; two or more nonvascular complications; more than two vessels injured; admission to ER in shock; injury to abdominal aorta or inferior vena cava; and injury to the porta hepatis. The majority of deaths (73%) were due to acute blood loss and irreversible shock. Factors unrelated to acute blood loss and shock had minimal effects on survival.

The continuing challenge of popliteal vascular injuries

During a 6 year period, 35 patients with 56 popliteal vascular injuries were treated. Thirty-three arteries and 23 popliteal veins were affected. Fifty-four percent of the patients had both an arterial and a venous injury. Twenty injuries were due to penetrating trauma and 15 injuries to blunt force. An overall amputation rate of 16 percent followed attempts at vascular repair. Blunt injuries were associated with a 30 percent amputation rate, whereas penetrating injuries were associated with only a 5 percent amputation rate. When our results were reviewed and compared with those of others, several factors important for determining the rate of limb salvage in popliteal vascular injuries were noted: (1) early recognition and prompt treatment, (2) absence of blunt injury with attendant soft tissue damage; (3) resection of damaged arterial tissue with end-to-end anastomosis or saphenous vein grafting in conjunction with the liberal employment of local heparin and a Fogarty catheter thrombectomy, (4) repair of concomitant popliteal venous injuries; (5) use of completion arteriography to reveal technical errors amenable to correction at time of operation; and (6) fasciotomy, used liberally but selectively.