Ravi Moonka

Percutaneous cholecystostomy for acute cholecystitis in veteran patients

BACKGROUNDnSurgical cholecystostomy has been shown to carry a significantly higher mortality rate at Veterans Administration (VA) hospitals than at non-federal hospitals in the past.nnnMETHODSnA retrospective outcomes study was undertaken at a large VA medical center with a policy favoring radiologic over surgical cholecystostomy over the past 9 years. Records of 24 consecutive patients with acute cholecystitis were reviewed to evaluate the effectiveness of the procedure.nnnRESULTSnCholecystostomy was performed radiologically in 22 patients and surgically in 2 patients. Most (78%) of patients improved within 48 hours. The periprocedural mortality was 25%. The majority of these patients died from unrelated illnesses. Four patients developed complications, none of which required operative intervention.nnnCONCLUSIONSnComorbidities are the most important mortality factor for cholecystostomies in VA patients. Radiologic tube placement is effective and uncomplicated in most cases.

The prevalence and natural history of gallstones in spinal cord injured patients

BACKGROUNDnIndividuals with a spinal cord injury are at increased risk for the development of gallstones. Because these patients cannot reliably manifest classic symptoms of biliary colic, they may be more likely to present with advanced biliary complications than patients with intact abdominal innervation. The natural history of gallstones in spinal cord injured patients has not been described.nnnSTUDY DESIGNnAll spinal cord injured patients seen at the Seattle Veterans Affairs Medical Center from January 1, 1993, to December 31, 1997 were included in the study. For each patient, the presence or absence of gallstones had been determined previously through screening abdominal ultrasonographic evaluations. Pertinent demographic information was obtained from medical records and patient interviews. Patients with gallstones were followed until death, cholecystectomy, or the conclusion of the study, and the annual incidence of biliary complications and patients requiring a cholecystectomy were determined. The prevalence of gallstones was established by studying the subset of patients seen at the Seattle Spinal Cord Injury Unit from January 1, 1995 to December 31, 1997.nnnRESULTSnAmong the spinal cord injured patients, 31% either had gallstones or had undergone a cholecystectomy at some point after their injury. Increasing age, female gender, and greater severity of injury were risk factors for the formation of gallstones. Over the first 5 years after the diagnosis of gallstones, the annual incidence of cholecystectomy or biliary complications was 6.3% and 2.2%, respectively.nnnCONCLUSIONSnSpinal cord injured patients are at increased risk for the development of gallstones. Patients with gallstones are at an increased risk for the development of biliary complications compared with neurologically intact patients, but the magnitude of this risk does not warrant prophylactic cholecystectomy.

Pathologic risk factors of occult malignancy in endoscopically unresectable colonic adenomas.

BACKGROUNDnWith the advent of new endoscopic and laparoscopic techniques, the likelihood of colonoscopically unresectable adenomas harboring occult malignancy influences management. While prior studies have evaluated polyp size and morphology in assessing the risk of malignancy, the relative risk of cancer based on the presence or absence of high-grade dysplasia has not been systematically studied.nnnMETHODSnFor all lesions preoperatively diagnosed as adenomas without invasive cancer, multivariate logistic regression analysis was performed to elicit independent variables associated with malignancy in the resected specimen.nnnRESULTSnOne hundred patients underwent a colectomy for preoperatively diagnosed adenomatous lesions. Multivariate logistic regression analysis revealed size, degree of dysplasia, and left-sided location to be independent predictors of malignancy.nnnCONCLUSIONSnIn colonic adenomas which are not amenable to simple colonoscopic resection, the most useful predictors of the lesion harboring a malignancy are polyp size and the presence of high-grade dysplasia, and these factors can help determine management.

Hypergastrinemia induced by proton pump inhibitor (PPI) causes pancreatic growth but does not promote pancreatic carcinogenesis

HYPERGASTRINEMIA INDUCED BY PROTON PUMP INHmITOR (PPI) CAUSES PANCREATIC GROWTH BUT DOES NOT PROMOTE PANCREATIC CARCINOGENESIS. Me Donald M. Jerome, Daniel S. Longnecker, Ravi Moonka, Linda Robinson, Richard H. Bell, Madigan Army Med Ctr, Tacoma, WA; Dartmouth Med Sch, Lebanon, NH; VA Puget Sound Health Care System, Seattle, WA; Univ of Washington, VA Puget Sound Health Care System, Seattle, WA.