Larry C. Carey

Decreased mortality of severe acute pancreatitis after proximal cytokine blockade

ObjectiveThis study determined the ability of interleukin-1 receptor antagonist (IL-1ra) to decrease the mortality of experimental acute pancreatitis. The response of the inflammatory cytokine cascade and its subsequent effects on pancreatic morphology were measured to determine the role of these peptides in mediating pancreatic injury. Summary Background DataPrevious studes have shown that proinflammatory cytokines are produced in large amounts during acute pancreatitis and that blockade at the level of the IL-1 receptor significantly decreases intrinsic pancreatic damage. The subsequent effect on survival is not known. MethodsA lethal form of acute hemorrhagic necrotizing pancreatitis was induced in young female mice by feeding a choline-deficient, ethionine supplemented (CDE) diet for 72 hours. For determination of mortality, the animals were divided into 3 groups of 45 animals each: control subjects received 100/μ L normal saline intraperitoneally every 6 hours for 5 days; IL-1ra early mice received recombinant interleukin-1 receptor antagonist 15 mg/kg intraperitoneally every 6 hours for 5 days beginning at time 0; IL-1ra late mice received IL-1 ra 15 mg/kg intraperitoneally every 6 hours for 3.5 days beginning 1.5 days after introduction of the CDE diet. A parallel experiment was conducted simultaneously with a minimum of 29 animals per group, which were sacrificed daily for comparisons of serum amylase, lipase, IL-1, IL-6, tumor necrosis factor-α, IL-1ra, pancreatic wet weight, and blind histopathologic grading. ResultsThe 10-day mortality in the untreated control group was 73%. Early and late IL-1ra administration resulted in decreases of mortality to 44% and 51%, respectively (both p < 0.001). Interleukin-1 antagonism also was associated with a significant attenuation in the rise in pancreatic wet weight and serum amylase and lipase in both early and late IL-1ra groups (all < 0.05). All control animals developed a rapid elevation of the inflammatory cytokines, with maximal levels reached on day 3. The IL-1ra-treated animals, however, demonstrated a blunted rise of these mediators (all p < 0.05). Blind histologic grading revealed an overall decrease in the severity of pancreatitis in those animals receiving the antagonist. ConclusionsEarly or late blockade of the cytokine cascade at the level of the IL-1 receptor significantly decreases the mortality of severe acute pancreatitis. The mechanism by which this is

The role of polymeric surface smoothness of biliary stents in bacterial adherence, biofilm deposition, and stent occlusion

Bacterial adherence and biofilm deposition onto the surface of polymers used for biliary stents are the initial events that ultimately lead to stent occlusion. Vivathane is a new polymer with an ultrasmooth surface. In this study, stents made from Vivathane were compared to standard plastic stents in an in vitro model. Polyethylene, C-flex, and Vivathane stents were connected in parallel and perfused with infected bile. The surfaces of the polyethylene and C-flex stents developed exuberant bacterial growth and biliary sludge deposition. Vivathane stents were nearly free of bacteria and demonstrated no propensity for biliary sludge deposition. These results indicate that polymeric surface irregularities promote bacterial adherence, biofilm deposition, and accumulation of biliary sludge. The ultrasmooth surface of Vivathane does not allow bacterial adherence and biofilm deposition. Vivathane holds promise as a new polymer for use in biliary stents in long-term applications.

Colorectal trauma : primary repair or anastomosis with intracolonic bypass vs. ostomy

This prospective, randomized, controlled study was undertaken to compare primary repair or anastomosis with intracolonic bypassvs.ostomy in severe colon and intraperitoneal rectal injury. Patients were randomized at surgery following confirmation of injury. Data collected included demographics, mechanism and location of injury, trauma score (TS), injury severity score (ISS), penetrating abdominal trauma index (PATI), complications, length of hospital stay, and hospital charges. Twenty-two patients were studied: 11 with intracolonic bypass and 11 controls. The experimental and control groups were statistically similar in demographics and mechanism of injury, severity of injury (TS=13.8vs.12.8; ISS=27.5vs.24.2; PATI=40.5vs.35.0), and complication rate. Length of stay (12.2 daysvs.20.7 days) and charges

TIPS Versus Peritoneovenous Shunt in the Treatment of Medically Intractable Ascites: A Prospective Randomized Trial

27,885vs.

Analysis of residual cancer after diagnostic breast biopsy: An argument for fine-needle aspiration cytology

53,599) tended to be greater in controls, and the comparison did not include subsequent colostomy closure. This study supports intracolonic bypass as a safe alternative to ostomy in severe colon and intraperitoneal rectal trauma.

Laparoscopic feeding jejunostomy: also a simple technique.

Objective:We undertook a prospective randomized clinical trial comparing TIPS to peritoneovenous (PV) shunts in the treatment of medically intractable ascites to establish relative efficacy and morbidity, and thereby superiority, between these shunts. Methods:Thirty-two patients were prospectively randomized to undergo TIPS or peritoneovenous (Denver) shunts. All patients had failed medical therapy. Results:After TIPS versus peritoneovenous shunts, median (mean ± SD) duration of shunt patency was similar: 4.4 months (6 ± 6.6 months) versus 4.0 months (5 ± 4.6 months). Assisted shunt patency was longer after TIPS: 31.1 months (41 ± 25.9 months) versus 13.1 months (19 ± 17.3 months) (P < 0.01, Wilcoxon test). Ultimately, after TIPS 19% of patients had irreversible shunt occlusion versus 38% of patients after peritoneovenous shunts. Survival after TIPS was 28.7 months (41 ± 28.7 months) versus 16.1 months (28 ± 29.7 months) after peritoneovenous shunts. Control of ascites was achieved sooner after peritoneovenous shunts than after TIPS (73% vs. 46% after 1 month), but longer-term efficacy favored TIPS (eg, 85% vs. 40% at 3 years). Conclusion:TIPS and peritoneovenous shunts treat medically intractable ascites. Absence of ascites after either is uncommon. PV shunts control ascites sooner, although TIPS provides better long-term efficacy. After either shunt, numerous interventions are required to assist patency. Assisted shunt patency is better after TIPS. Treating medically refractory ascites with TIPS risks early shunt-related mortality for prospects of longer survival with ascites control. This study promotes the application of TIPS for medically intractable ascites if patients undergoing TIPS have prospects beyond short-term survival.

Lessons Learned from the Evolution of the Laparoscopic Revolution

AbstractBackground: Diagnostic breast biopsy (DxBx) requires an effective strategy for strategy for successful treatment of breast cancer by lumpectomy or mastectomy. Clearance of margins is required to achieve local control.nMethods: We reviewed 844 malignant diagnostic biopsies. The strategy was to perform DxBx on all nonpalpable lesions and fine-needle aspiration (FNA) on all palpable lesions. When FNA was equivocal, DxBx was performed. After positive DxBx, either the biopsy cavity or FNA-positive breast mass was excised, and margins were documented with touch preparation cytology analysis (TPC) and frozen section (FS) as necessary to achieve negative margins.nResults: Ourside institutions referred 430 excisional biopsies. Two hundred twenty-five (52.3%) were found to have residual cancer at surgical excision. Our institution performed 414 biopsies: 169 were performed on nonpalpable lesions in which 58% had residual tumor at resection; 245 were diagnosed by FNA of palpable lesions. Residual disease was found in 12 (5%).nConclusions: Of patients who undergo DxBx, >50% have residual breast cancer. It is recommended that (a) FNA be performed on all palpable masses or DxBx of nonpalpable masses; when cancer is diagnosed, proceed to surgical excision. (b) When lumpectomy is the option, margins should be reexcised and intraoperatively evaluated with TPC and FS at the time of axillary dissection.

Adenoma of the Ampulla of Vater:A Genetic Condition?

SummaryPlacement of feeding tubes is a common procedure for general surgeons. While the advent of percutaneous endoscopic gastrostomy has changed and improved surgical practice, this technique is contraindicated in many circumstances. In some patients placement of feeding tubes in the stomach may be contraindicated due to the risks of aspiration, gastric paresis, or gastric dysmotility. We describe a technique of laparoscopic jejunostomy tube placement which is easy and effective. It is noteworthy that this method may be used in patients who have had previous abdominal operations, and it has the added advantage of a direct peritoneal view of the viscera. We suggest that qualified laparoscopic surgeons learn the technique of laparoscopic jejunostomy.

32P as an Adjunct to Standard Therapy for Locally Advanced Unresectable Pancreatic Cancer: A Randomized Trial

After 100 years of practice, the face of general surgery changed forever when laparoscopic cholecystectomy was introduced. The impact was felt in how new procedures were taught and learned, proficiency determined, and credentials established. In addition, the revolution of laparoscopic surgery brought to bear ethical considerations and the harsh reality of medical legal and economic ramifications of new technology introduction. Finally, minimally invasive surgery challenged dogma of traditional perioperative care, allowing streamlining of postoperative recovery.

Transjugular intrahepatic portasystemic stent shunt in the treatment of variceal bleeding in hepatocellular cancer

The etiology of adenoma of the ampulla of Vater is not well understood. Previous authors reported the association of this neoplasm with polycystic kidney disease of two fraternal sisters. They concluded that these two conditions were somehow related. We describe a case of ampullary adenoma associated with polycystic kidney disease. This presentation raises again the question of a possible link between these two diseases.