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David A Iannitti

Publications and source records attributed to David A Iannitti.

11 recordsLinked to original sources
PubMed2006

Use of the round ligament of the liver to decrease pancreatic fistulas: a novel technique.

BACKGROUND: The reported pancreatic anastomosis fistula rate for pancreaticoduodenectomy, distal pancreatectomy, or enucleation is 2% to 27%. We hypothesized that reinforcement with a vascular pedicle would decrease the number of fistulas. We report a novel technique: the use of the round ligament of the liver to reinforce the pancreatic anastomosis after resection. STUDY DESIGN: Patients undergoing resection from January 1, 2000 until August 8, 2005, at a tertiary referral center, were followed in a retrospective cohort study. The round ligament of the liver was disconnected from the abdominal wall, from the umbilicus to the liver. After pancreatic resection, it was sutured to the anastomosis or closure. A pancreatic fistula was defined as follows: Jackson-Pratt (JP) drainage>50 mL/d, after the fifth postoperative day, with amylase>3 times the serum level; reexploration for a fistula; postoperative pseudocyst; or death from sepsis with a presumed fistula. RESULTS: In 95 patients, we were able to mobilize the round ligament and use it as a vascular pedicle. The overall fistula rate for the series was 5.3% (5 of 95) and for pancreaticoduodenectomy it was 8.8% (5 of 57). There were no fistulas within the distal pancreatectomy and enucleation group (n=38). Importantly, there was no mortality from pancreatic fistula in the studied patients and no need for operative intervention for a fistula. CONCLUSIONS: We present a novel technique to prevent pancreatic fistula. Although randomized trials are necessary, it appears that the use of the round ligament as a vascular pedicle for reinforcing the pancreatic anastomoses and resections results in a very low number of pancreatic fistulas.

Adult↗
PubMed2006

Minilaparoscopic transgastric cystgastrostomy.

BACKGROUND: A technique combining upper endoscopy with percutaneous transgastric minilaparoscopic instrumentation for the formation of pancreatic cystgastrostomy is safe and effective for the internal drainage of pancreatic pseudocysts. METHODS: At a tertiary-care academic medical center, 6 patients with pancreatic pseudocysts with a mean size of 19 cm (range, 16-23 cm) were selected for combined endoscopic and percutaneous transgastric minilaparoscopic (1.7-2 mm) pancreatic cystgastrostomy. All pseudocysts had been followed-up for a minimum of 5 weeks (range, 5-22 wk) and were noted to significantly displace the stomach anteriorly. RESULTS: The mean surgical time was 98 minutes (range, 45-150 min). The mean amount of fluid removed from the pseudocysts was 2167 mL (range, 1600-2600 mL). All ports were removed from the stomach without the need to suture the gastric wall or skin except for 2 gastric serosal sites that were closed with a single intracorporeal stitch. The length of hospital stay averaged 2.2 days (range, 0-6 d). All patients were discharged in good condition, tolerating a regular diet. With a mean follow-up period of 13.4 months (range, 1-30 mo), all patients remain asymptomatic from their pancreatic pseudocysts. CONCLUSIONS: The technique of combining upper endoscopy with percutaneous transgastric minilaparoscopic instruments to create a pancreatic cystgastrostomy can be used to apply well-established surgical principals for internal drainage and has the potential to be used for the management of other gastric pathology.

Adolescent↗
PubMed2006

Improved hepatic transduction, reduced systemic vector dissemination, and long-term transgene expression by delivering helper-dependent adenoviral vectors into the surgically isolated liver of nonhuman primates.

Helper-dependent adenoviral vectors (HDAds) are attractive vectors for liver-directed gene therapy because they can mediate sustained, high-level transgene expression without chronic toxicity. However, high vector doses are required to achieve efficient hepatic transduction by systemic delivery because of a nonlinear dose response. Unfortunately, such high doses result in systemic vector dissemination and dose-dependent acute toxicity with potentially severe and lethal consequences. We hypothesize that the threshold to efficient hepatic transduction may be circumvented by delivering the vector into the surgically isolated liver via the portal vein. Total hepatic isolation was achieved by occluding hepatic inflow from the portal vein and hepatic artery and by occluding hepatic venous outflow at the inferior vena cava. We demonstrate in nonhuman primates that this approach resulted in significantly higher efficiency hepatic transduction with reduced systemic vector dissemination compared with systemic intravascular delivery. This method of delivery was associated with transient acute toxicity, the severity of which was variable. Importantly, stable, high levels of transgene expression were obtained for at least 665 days for one baboon and for at least 560 days for two baboons with no evidence of long-term toxicity.

Adenoviruses, Human↗
PubMed2006

Intraoperative triple antenna hepatic microwave ablation.

OBJECTIVE: Microwave ablation is emerging as a new treatment option for patients with unresectable hepatic malignancies. This two-center study shows the results of a phase 1 clinical trial of patients with known hepatic masses who underwent synchronous triple antenna microwave ablation before elective hepatic resection. SUBJECTS AND METHODS: Intraoperative microwave ablation was performed before hepatic resection. Hepatic lesions were targeted using real-time intraoperative sonography with three microwave antennas positioned in a triangular configuration. Microwave ablation was performed at 45 W for 10 minutes. Hepatic resection was then completed in the standard fashion. Gross specimens were sectioned and measured to determine tumor and ablation sizes. Representative areas were stained with H and E stain and vital histochemical nicotinamide adenine dinucleotide (NADH) stain. RESULTS: Ten patients with a mean age of 64 years (range, 48-79 years) were treated. Tumor histology included colorectal carcinoma metastases and hepatocellular carcinoma. The mean maximal tumor diameter was 4.4 cm (range, 2.0-5.7 cm). The mean maximal ablation diameter was 5.5 cm (range, 5.0-6.5 cm), while the average ablation zone volume was 50.8 cm3 (range, 30.3-65.5 cm3). Gross and microscopic examinations of areas after microwave ablation showed clear coagulation necrosis, even surrounding large hepatic vessels (> 3 mm in diameter). A marked thermallike effect was observed with maximal intensity closest to the antenna sites. NADH staining confirmed the uniform absence of viable tumor in the ablation zone. CONCLUSION: This study shows the feasibility of using multiple microwave antennas simultaneously in the treatment of liver tumors intraoperatively. Additional percutaneous studies are currently under way to investigate the safety and efficacy in treating nonsurgical candidates.

Aged↗
PubMed2005

Minimally invasive tension-free inguinal hernia repair.

With a growing understanding of abdominal wall mechanics and improving surgical technology, inguinal herniorrhaphy has undergone significant advancements in the past 100 years. As primary repair through an anterior approach gave way to the "tension-free" Lichtenstein technique in the later part of the 20th century, hernia recurrence rates fell dramatically. With this fall in recurrence rates, other postoperative factors became the measure of herniorrhaphy technique quality. The reductions of postoperative pain and recovery time have become the basis for comparison between techniques. To that end, the plug and patch methods of Millikan and Rutkow, as well as the Kugel memory recoil mesh repair system, adhere to the philosophy of minimal dissection and suturing. The Prolene Hernia System was similarly created to simplify hernia repair while improving postoperative recovery. The posterior approach to hernia fixation was well-described in the late 1800s. Although generally underused, this technique offered an excellent option for repairing all inguinal hernias, especially incarcerated ones. By combining the perspective of preperitoneal repair with laparoscopic technology, a truly novel option for herniorrhaphy was created. Laparoscopy offers lower recurrence and postoperative complication rates than standard primary open repair, with the potential for a faster and more comfortable recovery than the "tension-free" open repair.

Hernia, Inguinal↗
PubMed2003

Portal venous gas detected by computed tomography: is surgery imperative?

BACKGROUND: Portal vein gas (PVG) has historically been associated with mortality rates of 75% or higher and mandatory abdominal exploration. The following study reassesses the clinical significance of gas in the portal venous system detected by computed tomography (CT) and reevaluates the need for surgical intervention in that setting. METHODS: We performed a retrospective chart review of 26 patients presenting with gas in the portal venous system as imaged by CT between August 1, 1993 and April 8, 2001. Characteristics assessed included age, sex, clinical presentation and course, additional CT findings, diagnosis, surgical versus non-surgical management, surgical findings, pathologic correlation, and mortality. RESULTS: Of the 26 patients who had gas in the portal venous system by CT, 11 underwent surgery to determine underlying pathology. Of those who underwent surgery, 8 survived to be discharged while 3 died (73% surgical survival). The survivors presented with gastrointestinal related signs/symptoms and were found at the time of surgery to have adhesions, non-surgically treated inflammation, unclear pathology, or resectable lesions. Those who died all demonstrated marked bowel ischemia intraoperatively. Among patients who did not undergo surgery, 9 survived and 6 died (60% nonsurgical survival). Those who survived presented either asymptomatically or with pathology including acute pancreatitis, recent hypotensive episode, uncomplicated diverticulitis, unresectable colon cancer, or infectious etiology. Those who died were poor surgical candidates or status postvascular procedure. The overall survival in patients with portal venous gas by CT was 65%. CONCLUSION: Portal venous gas on CT is associated with a wide range of pathologies that do not necessarily warrant surgical management. Clinical presentation should be correlated with the presence of PVG and other associated CT findings prior to deciding whether surgery should be performed.

Adult↗
PubMed2003

Combined modality therapy for pancreatic cancer.

In spite of the high mortality in pancreatic cancer, significant progress is being made. This review discusses multimodality therapy for patients with pancreatic cancer. According to several phase II trials and Gastrointestinal Tumor Study Group results, improvements in locoregional control and survival may be achieved when chemotherapy is added to radiation for locally advanced pancreatic cancer. Radiosensitizing chemotherapy agents such as 5-fluorouracil, gemcitabine, paclitaxel, and cisplatin have shown promise. Selected patients with locally advanced disease have been downstaged with chemoradiation, facilitating surgical resection. For patients with resectable disease, the completion of Radiation Therapy Oncology Group study 97-04 represents a major achievement and brings gemcitabine into the forefront of adjuvant therapy. Neoadjuvant chemoradiation may eliminate the delay of initiating adjuvant treatment and spare unnecessary surgery for patients with rapid systemic progression. Molecular agents are being combined with chemoradiation in an attempt to delay or prevent systemic progression.

Antineoplastic Agents↗
PubMed2002

Hepatic radiofrequency ablation.

HYPOTHESIS: Hepatic radiofrequency ablation (RFA) is effective in treating patients with unresectable hepatic malignancies. DESIGN: Case series of 123 patients with unresectable hepatic tumors or tumors with histological findings not traditionally treated by means of hepatic resection were considered for hepatic RFA. Median follow-up was 20 months. SETTING: Tertiary referral center. PATIENTS: The 123 patents underwent 168 RFA sessions from January 1, 1998, through September 30, 2001. Sixty-nine patients were male and 54, female; average age was 65 years (range, 1-89 years). Fifty-two patients had metastatic colorectal cancer; 30, hepatocellular carcinoma; and 41, cancers with other histological findings. INTERVENTIONS: A 200-W, cooled-tip RF probe system was used for all cases. Probe placement and ablation were monitored by means of real-time ultrasonography or fluoroscopic computed tomography. Final tissue temperature of greater than 50 degrees C was achieved in all cases. RESULTS: Initial treatment sessions were percutaneous in 87 patients, open operations in 33, and laparoscopic in 3. Repeated sessions were percutaneous in all but 2 patients. The mean number of lesions treated per session was 2.7 (range, 1-24). Mean tumor size was 5.2 cm (range, 0.5-15.0 cm). One death occurred within 30 days of a procedure. No hepatic bleeds, bile leaks, or adult respiratory distress syndrome occurred. Overall morbidity was 7.1%. Complications included hepatic abscesses in 4 patients, transient liver insufficiency in 3, segmental hepatic infarcts in 2, diaphragm paralysis in 1, hepatic artery-to-portal vein fistula in 1, and systemic hemolysis in 1. CONCLUSIONS: Hepatic RFA is an effective treatment option for patients with unresectable hepatic malignancies. Careful patient selection based on tumor size, location, and number and on patient clinical status should determine the choice of treatment. Further controlled trials are needed to determine the effect of hepatic RFA on long-term survival.

Adolescent↗
PubMedDate not supplied

Subphrenic and pleural abscess due to spilled gallstones.

BACKGROUND: A 70-year-old male approximately 3 years after laparoscopic cholecystectomy presented to his primary care physician with a 4-month history of generalized malaise. METHODS: A workup included magnetic resonance imaging that revealed a perihepatic abscess. The patient underwent ultrasound-guided drainage, with the removal of 1400 mL of purulent fluid and placement of 2 drains. Computed tomographic scanning showed resolution, and he was discharged home on oral antibiotics. At 2-month follow-up, the patient was asymptomatic, denying any constitutional symptoms. However, abdominal computed tomographic scanning revealed recurrence of the abscess, which measured approximately 18 x 9 x 7.5 cm, with mass effect on the liver. The patient was placed on intravenous antibiotics and scheduled for operative drainage. The abdomen was entered with a right subcostal incision, and 900 mL of purulent fluid was drained. We also noted abscess erosion through the inferolateral aspect of the right diaphragm into the pleural space. The pleural abscess was loculated and isolated from the lung parenchyma. Palpation within the abscess cavity revealed 9 large gallstones. Following copious irrigation and debridement of necrotic tissue, 3 drains were placed and the incision was closed. RESULTS: The patient had an uneventful recovery and was discharged home on postoperative day number 6. Follow-up imaging at 3 months demonstrated resolution of the collection. CONCLUSION: Spillage of gallstones is a complication of laparoscopic cholecystectomy, occurring in 6% to 16% of all cases. Retained stones rarely result in a problem, but when complications arise, aggressive surgical intervention is usually necessary.

Abscess↗