A letter to the President.
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Acquired Immunodeficiency Syndrome↗
Biomedical subjects
J Pickleman
Publications and source records attributed to J Pickleman.
Diagnosis, surgical intervention, and prognosis of primary pancreatic lymphoma.
Primary pancreatic lymphoma is a rare but treatable malignancy that may present as an isolated pancreatic mass. Most of these patients are assumed to have ductal malignancies of the pancreas and are denied surgical intervention. Controversy exists concerning the method of diagnosis and the need for and extent of surgical intervention for these malignancies. Over the past 15 years, from 1976-1991, we have treated seven patients with pancreatic lymphoma who initially presented with a pancreatic mass. There were five females and two males ranging in age from 60-86 years (mean = 68). All patients were symptomatic and complained of epigastric pain, jaundice, anorexia, or early satiety. The interval between onset of symptoms and treatment averaged 6 weeks. Over half of these patients presented with an epigastric mass and/or jaundice. Abdominal CT scan was accurate in identifying and localizing the pancreatic mass in all patients. The diameter of the pancreatic mass ranged from 3-12 cm (mean = 8.1 cm) and the mass was located in the head of the pancreas in five patients. All attempted percutaneous needle biopsies of the pancreatic mass were non-diagnostic. Operative lymph node biopsy or transduodenal/wedge biopsy of the pancreatic mass was successful in demonstrating pancreatic lymphoma in all patients. Two of the seven patients underwent biliary bypass. One of the seven patients died in the postoperative period. Three of these seven patients received chemotherapy and survived an average of 6.3 years. One patient is alive 8 years after diagnosis and treatment and is currently asymptomatic. Patients who did not receive postoperative chemotherapy survived an average of 5 months.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Laparoscopic cholecystectomy bile duct injuries: more than meets the eye.
Laparoscopic cholecystectomy (LC) has rapidly become standard treatment of symptomatic cholelithiasis. Its advantages are well known, while its risks have not been well defined. The most common major complication of LC is bile duct injury. Over the past year, we have treated six patients for this problem. Injuries included: one partial laceration of the common bile duct; one partial laceration of the common hepatic duct; three complete common hepatic duct transections at the bifurcation, and one clip obstruction of the right hepatic duct. Intraoperative cholangiography was performed in two of six patients. Injury was recognized in these two cases, which were converted to celiotomy for immediate repair. One was repaired primarily; the other required a hepaticojejunostomy. Injuries were not identified at LC in four. Three of the four patients required biliary-enteric reconstruction procedures. With a mean follow-up period of 13 months, four of six patients remain symptomatic. LC does carry a real risk of bile duct injury. Routine intraoperative cholangiography may decrease this risk or at least allow early recognition and repair when it has occurred. Conversion to an open procedure is not a complication of LC but rather a sign of good surgical judgement. Patients not following the routine postoperative course must be evaluated for a possible bile duct injury to prevent the morbidity of delayed diagnosis.
Adolescent↗
Ceftriaxone-induced cholelithiasis.
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Adult↗
"A glass a day keeps the doctor...".
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History, 17th Century↗
Less is better. The diagnostic workup of the patient with obstructive jaundice.
The typical patient with suspected obstructive jaundice is often subjected to an extensive preoperative workup on the premise of providing surgeons with information that will aid them at exploration. A 15-year review of 83 patients with obstructive jaundice from the common periampullary carcinomas was carried out and indicated that obtaining such information was unnecessary, unsafe, costly, and time-consuming. It is recommended that the patient with a medical history and liver function test results suggestive of obstructive jaundice should undergo an abdominal ultrasound study. If this discloses distal bile duct obstruction, no further tests are necessary in most patients and the operation should be carried out promptly.
Adult↗
The management of patients with suspected early postoperative small bowel obstruction.
A 10-year review of 101 patients sustaining an early postoperative small bowel obstruction within 30 days of celiotomy was carried out. Signs, symptoms, lab tests, and x-rays did not indicate which patients required operation. Twenty-three patients were operated on for either failure to resolve their obstruction or because it was feared that ischemic bowel was present. In none of these patients, nor the 78 patients who resolved without reoperation, did dead bowel occur. Early postoperative small bowel obstruction was most often due to adhesions and inflammatory processes. Seven patients died (6.9%), three in the operated and four in the nonoperated group. Because ischemic bowel is very unlikely in patients with early postoperative small bowel obstruction, we advise 10 to 14 days of nasogastric suction initially; after this, improvement is unlikely without reoperation.
Abdomen↗
Pheochromocytoma multisystem crisis. A surgical emergency.
Three of 27 patients treated for pheochromocytoma between 1974 and 1987 presented with pheochromocytoma multisystem crisis (PMC). This unusual presentation consists of multiple organ system failure, temperature often greater than 40 degrees C, encephalopathy, and hypertension and/or hypotension. Although urgent medical therapy achieved blood pressure control in all three patients, the other manifestations of PMC progressed rapidly in spite of alpha and even beta blockade. The first patient died during attempts to localize a septic focus. The other two patients underwent urgent adrenalectomy and had postoperative improvement in their multiple organ system failure. All three tumors were large and produced markedly elevated levels of epinephrine. In conclusion (1) PMC is an unusual presentation of pheochromocytoma; (2) its manifestations include multiple organ system failure, high fever, encephalopathy, and vascular lability; (3) it may result from increased epinephrine secretion; and (4) successful treatment of PMC demands prompt diagnosis, vigorous medical preparation, and emergency tumor removal if the patient's condition continues to deteriorate.
Adrenal Gland Neoplasms↗
Diaphragmatic neurilemoma.
The fourth case of diaphragmatic neurilemoma reported in the English literature is presented from our institution. Diaphragmatic tumors are usually benign and most are symptomatic. Utilizing CT scanning, these tumors can today be accurately localized. Excision via thoracotomy or celiotomy is easily accomplished and is the only reliable way to establish the identity of these lesions.
Diaphragm↗
Treatment of pancreatic cutaneous fistulas with a somatostatin analog.
Five pancreatic cutaneous fistulas were treated by subcutaneous administration of a long-acting synthetic analog of somatostatin, SMS 201-995. Patients included four men and one woman who ranged in age from 52 to 77 years. The fistulas developed after drainage of a pancreatic abscess, biopsy of a pancreatic mass, splenectomies for idiopathic thrombocytopenic purpura and Felty's syndrome, and operative trauma, respectively. Fistula output consisted of 1,000 ml/day of amylase- and lipase-rich fluid in the patient with a pancreatic biopsy. The other four patients had low-output fistulas (100 to 250 ml/day) that had been draining for 1 to 12 months. Direct communication with the pancreatic duct was demonstrated by endoscopic retrograde cholangiopancreatography, sinography, or both in four of the five patients. Fistula output decreased from 340 +/- 376 ml/day to 63 +/- 36 ml/day on the first day of therapy with two daily doses of 0.05 mg SMS 201-995 (p less than 0.03) and to 13 +/- 19 ml/day on the seventh day of therapy (p less than 0.03). Two patients had prompt closure of their fistulas and one closed in 3 months. One patient with chronic pancreatitis and a duct stricture and one patient with recurring infection did not achieve permanent fistula closure with SMS 201-995. Because of its safety, ease of administration, and efficacy in decreasing fistula output, we believe somatostatin analog therapy is beneficial in hastening closure of pancreatic fistulas.
Aged↗
The use and abuse of neuropsychological tests to predict operative performance.
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Clinical Competence↗
The role of percutaneous drainage of pancreatic abscesses.
Pancreatic abscess remains the most lethal form of intra-abdominal abscess despite a wide variety of operative approaches that have been advocated for its control. Mortality is frequent, and recurrent abscesses after operative drainage are common. Death often results from ongoing uncontrolled sepsis. The role of percutaneous drainage (PCD) of pancreatic abscesses is controversial. Recent experience with five patients who had pancreatic abscess and in whom a combination of operative drainage and PCD proved instrumental in survival leads the authors to recommend the consideration of both forms of drainage dependent upon the circumstances. Specifically, indications for PCD may include the following: use as a temporizing measure prior to celiotomy in a critically ill patient; use in postoperative patients who have recurrent abscesses and in whom the presence of dense inflammation precludes safe evacuation of pus; and use in the patient who has known portal hypertension and in whom massive bleeding is likely to result from celiotomy and abscess drainage.
Abdomen↗
The improving results of cholecystectomy.
We reviewed the outcome of 389 consecutive patients undergoing cholecystectomy during the ten-year period from 1973 to 1983. Significant discrepancies between this series and other published data were noted as follows: Patients with acute cholecystitis, although older, had comparable morbidity and mortality rates with patients undergoing elective cholecystectomy. Diabetic and nondiabetic patients with acute cholecystitis had similar outcomes. In those patients with acute cholecystitis, delay in operation after hospital admission did not increase operative technical difficulties, morbidity, or length of postoperative hospitalization, although total hospitalization was prolonged. The histologic reports of gallbladder pathology in those patients with a clinical diagnosis of acute cholecystitis did not disclose acute inflammatory changes in 39% of cases, raising questions about the validity of previous reviews of patients with acute cholecystitis in which the microscopic diagnosis alone was used.
Acute Disease↗
Controversies in biliary tract surgery.
There are many controversies regarding the surgical management of calculous gallbladder disease. Newer data in the surgical literature and competing medical treatments compound this confusion. In this guest lecture the author reviews current data and provides an update in seven controversial areas: the timing of operation in acute cholecystitis, the management of the diabetic patient with gallstones, the treatment of the patient with asymptomatic gallstones, the medical treatment of gallstones, the use and abuse of operative cholangiography, the management of the patient with gallstone pancreatitis and management of the patient with acalculous cholecystopathy.
Acute Disease↗
The role of sincalide cholescintigraphy in the evaluation of patients with acalculus gallbladder disease.
Thirty-six patients with biliary colic and normal oral cholecystograms, upper gastrointestinal tract roentgenograms, and results of gallbladder ultrasonography underwent sincalide-stimulated biliary excretion scanning. Nineteen of these patients subsequently underwent cholecystectomies. Gallbladder ejection fractions (EFs) ranged from 0% to 88% (mean, 38%) and nine of 19 patients had exact pain reproduction with sincalide. All patients except one (EF, 35%) were cured of their symptoms. However, five patients were also cured who had a normal EF (greater than 50%). Histologically, 11 gallbladders showed chronic cholecystitis and eight were normal. We conclude that the sincalide biliary excretion scan is a useful test to study this group of patients. In patients with a decreased EF, cholecystectomy can be recommended with a high probability of symptom relief. In patients with normal EFs, clinical judgment is required, as some of these patients (five of five in this series) may still benefit from operation.
Adult↗
Intra-abdominal abscess unassociated with prior operation.
During the past five years, 65 patients were treated for intra-abdominal abscesses unassociated with prior operation. Radiologic tests proved quite accurate in confirming the diagnosis. Abdominal x-ray films were abnormal in 25 (57%) of 44 patients, as were ultrasonograms in 33 (89%) of 37 patients, computed tomography scans in 13 (100%) of 13 patients, and gallium scans in five (100%) of five patients. Celiotomy was performed in each patient with both abscess drainage and the appropriate management of the diseased organ. Seven patients (10.8%) died, and in five death was due to uncontrolled sepsis. Duration of hospitalization averaged 23 days (seven days preoperatively and 16 days postoperatively). Twenty-two (34%) of 65 patients had an incorrect preoperative diagnosis leading to prolonged antibiotic treatment and delay in operation. The mortality was significant in seven (10.8%) of 65 patients, unrelated to the type of operative drainage (Penrose v sump) but clearly related to uncontrolled intra-abdominal sepsis. A heightened suspicion of this problem should allow for an earlier diagnosis and an improved outcome. Prompt abdominal reexploration is indicated in those patients manifesting continued evidence of sepsis or organ failure.
Abdomen↗
Endoscopic removal of an intragastric Angelchik antireflux prosthesis.
Four months after insertion of an Angelchik esophageal antireflux prosthesis, a 60-year-old man was seen with epigastric pain and vomiting. Upper gastrointestinal studies demonstrated intragastric migration of the prosthesis. The prosthesis was intact and the straps were untied , and gastroscopic removal was accomplished by pulling out the prosthesis. Surgeons using this prosthesis should be aware of this unique potential complication of erosion into a viscus.
Endoscopy↗
Age, gender, lateral dominance, and prediction of operative skill among general surgery residents.
Ability patterns and surgical proficiency were examined in matched groups of general surgery residents selected on the basis of age, gender, or hand preference from a population of 141 residents who had completed neuropsychologic tests of visuospatial, psychomotor, and stress tolerance abilities and had been rated on 12 aspects of technical skill exhibited during 1480 operative procedures. Older residents (ages 28 to 42 years) exhibited less motor speed (p less than 0.05) and coordination (p less than 0.005) and more caution in avoiding psychomotor errors (p less than 0.05) than did their younger counterparts. No differences were found for visuospatial abilities, stress tolerance, or rated surgical skill. These findings indicate that although age does appear to adversely affect pure motor skills, these are not important components of operative proficiency. Female residents exhibited superior (p less than 0.05) academic achievement (MCAT, Verbal and National Boards Part II) as compared with their male counterparts. They also excelled on a signal detection task requiring identification of visual patterns. However, the women scored less well (p less than 0.05) than men on a visuomotor task demonstrated to be a significant predictor of operative skill. Greater cautiousness in avoiding errors may be a contributing factor to their reduced efficiency on this task. In comparison to male controls, female residents received consistently lower surgical skills ratings, particularly on items measuring confidence and task organization. Left-handed residents were more reactive to stress (p less than 0.03), more cautious (p less than 0.04), and more proficient on a neuropsychologic test of tactile-spatial abilities (p less than 0.03) than right-handed counterparts. Although these traits correlated positively (p less than 0.05) with rated operative skill within the left-handed group, the group received consistently lower ratings than did right-handed residents. The inconvenience of assisting left-handed residents may overshadow attending surgeons' perceptions of their innate abilities. These findings demonstrate significant, neuropsychologically based differences among surgery residents that pose unique challenges to persons responsible for their selection and training.
Adult↗