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Biomedical subjects

R A Prinz

Publications and source records attributed to R A Prinz.

At least 19 recordsLinked to original sources
PubMed1992

Adenocarcinoma of the pancreas coexisting with pancreatic abscess.

Of 20 patients treated for pancreatic abscess during the years 1984-1991, two patients were found to have adenocarcinoma of the pancreas associated with their pancreatic abscesses. In one patient an adenocarcinoma of the proximal pancreas caused ductal obstruction, which may have been the primary cause of an abscess distal to the tumor. In the second patient, metastatic adenocarcinoma of the pancreas and a concurrent pancreatic abscess were found when the patient's abdomen was explored for complications related to gallstone pancreatitis. In both patients, the tumor was unresectable at presentation. A detailed review of these cases is presented as well as a review of the related literature.

Abscess↗
PubMed1992

Selective intra-arterial methylene blue injection: a novel method of localizing gastrinoma.

A 40-year-old woman had persistent Zollinger-Ellison syndrome despite excision of a 4-cm duodenal gastrinoma. Localizing studies including ultrasonography, computed tomography, magnetic resonance imaging, duodenal endoscopy, endoscopic ultrasonography, and intraoperative endoscopic transillumination of the duodenum failed to detect a tumor. Selective intra-arterial methylene blue injection was used to identify a 6-mm gastrinoma in the duodenum, which was locally excised. Postoperatively, the patient had a negative secretin provocative test result. This novel method uses selective arterial secretin injection with hepatic venous gastrin sampling to identify the vessel feeding the gastrinoma. An angiographic catheter is then positioned in this artery. At laparotomy, methylene blue is injected through this catheter to selectively stain the gastrinoma, facilitating its identification. Selective intra-arterial methylene blue injection can enhance intraoperative detection of small gastrinomas and may improve the rate of curative resection in the Zollinger-Ellison syndrome. Further evaluation of this novel localizing technique is warranted.

Adult↗
PubMed1992

Effect of somatostatin analogue and cholecystokinin receptor antagonist on bile-induced acute canine pancreatitis.

To determine whether a synthetic somatostatin analogue, octreotide, and a cholecystokinin receptor antagonist, L-364,718, may be beneficial in acute pancreatitis, 33 dogs were assigned to four groups. Each dog underwent laparotomy with injection of autologous bile into the dorsal pancreatic duct. Thirty minutes after the induction of pancreatitis, Group 1 received a subcutaneous injection of octreotide (200 micrograms/kg), Group 2 received an equal volume of the octreotide carrier, Group 3 received an hourly intravenous bolus of L-364,718 (60 micrograms/kg), and Group 4 received an equal volume of the L-364,718 carrier. Hemodynamic profiles, arterial blood gases, plasma glucose, and serum amylase were obtained before laparotomy, at bile injection, and at hourly intervals. The pancreas was removed after 8 hours for gross evaluation, measurement of water content, and histologic examination. A significant decrease in cardiac index and a significant increase in serum amylase and pancreatic edema occurred in all four groups 8 hours after the induction of pancreatitis (P less than 0.05), but there was no statistical difference between any group. Likewise, there was no difference in gross or histologic changes in the pancreas of any group. The somatostatin analogue, octreotide, and the cholecystokinin receptor antagonist, L-364,718, did not ameliorate the effects of severe, bile-induced pancreatitis in dogs.

Acute Disease↗
PubMed1992

Laparoscopy: the preferred method of cholecystectomy in the morbidly obese.

BACKGROUND: Morbid obesity has been considered a contraindication to laparoscopic cholecystectomy (LC). METHODS: To evaluate this we reviewed our first 201 patients undergoing LC and compared the operative procedure and outcome in morbidly obese (greater than or equal to 100 pounds over ideal body weight [IBW]) and nonobese patients. We also compared a group of morbidly obese patients who underwent standard open cholecystectomy (n = 11) with the obese group undergoing LC (n = 21). All groups were comparable in terms of age, sex, and symptoms (acute vs chronic). The obese groups undergoing LC and open cholecystectomy had similar weights (134.0 +/- 9.4 pounds over IBW [range, 100 to 286 pounds] and 133.8 +/- 6.0 pounds over IBW [range, 108 to 170 pounds], respectively) and were significantly different from the nonobese group undergoing LC (28.3 +/- 2.0 pounds over IBW [range, 23 to 98 pounds]). Parameters evaluated included operative time, resumption of normal diet, length of postoperative hospitalization, complications, conversion to open procedure, and ability to perform cholangiography. RESULTS: There were no statistically significant differences between the obese and nonobese groups undergoing LC in any parameters studied (operative time, 151.7 +/- 4.0 minutes vs 160.7 +/- 9.9 minutes; tolerance of diet, 1.2 +/- 0.1 days vs 1.1 +/- 0.1 days; time to discharge, 2.0 +/- 0.1 days vs 1.8 +/- 0.2 days; complications, 7.0% vs 0.0%). Operative time (117.6 +/- 11.6 minutes) was shorter (p = 0.45) in obese patients undergoing open cholecystectomy. However, time to normal diet and length of postoperative hospitalization were significantly longer (3.1 and 4.6 days, respectively; p less than 0.01), and there were more complications (18.2%). CONCLUSIONS: Rather than being contraindicated in the morbidly obese, LC appears to be the preferred method of cholecystectomy.

Body Weight↗
PubMed1992

Secondary pancreatic infections: are they distinct clinical entities?

BACKGROUND: Infected pseudocysts, pancreatic abscesses, and infected pancreatic necroses have been proposed as distinct clinical entities in terms of treatment and outcome. To evaluate this classification, we reviewed the clinical course and bacteriologic findings of pancreatic infections. METHODS: Of 1299 patients with pancreatitis or a related complication admitted over a 7-year period, 64 (4.9%) with culture-documented secondary pancreatic infections were reviewed with regard to cause, clinical course, bacteriologic findings, and outcomes. RESULTS: Group I consisted of 23 patients with infected pseudocysts; group II, 20 patients with pancreatic abscesses; and group III, 21 patients with infected pancreatic necrosis. The causes were alcohol in 36%, biliary tract disease in 30%, and postoperative in 16%, with no significant difference between groups. Patients in group I had abdominal pain or a mass without accompanying signs of sepsis, whereas patients in groups II and III had sepsis. In group I, 15 patients were treated with internal drainage, four with percutaneous drainage, and four with external drainage. In group II, three had percutaneous drainage, 15 operative drainage, and two open packing. In group III, 19 patients had operative drainage and two had open packing. Morbidity occurred in 26% of patients in group I, 40% in group II, and 90% in group III (p less than 0.001). Mortality rates were 9% in group I, 25% in group II, and 48% in group III (p less than 0.01). Enteric organisms were present in 66% of isolates, with no difference between groups, suggesting a common mode of infection. CONCLUSIONS: Despite similar bacteriologic findings, infected pseudocysts, pancreatic abscesses, and infected pancreatic necroses have significantly different presentations, clinical courses, and outcomes, confirming that they are distinct entities. This distinction is important when therapeutic outcomes are compared.

Abscess↗
PubMed1991

Granulocyte-macrophage colony stimulating factor for the treatment of drug induced agranulocytosis.

Drug induced agranulocytosis is an uncommon but potentially fatal complication. In some cases, it may be associated with hypoplasia and depletion of granulocytic precursors in the marrow, leading to prolonged neutropenia. We report on the use of granulocytic-macrophage colony stimulating factor (GM-CSF) in two such cases, at a dose of 10 micrograms per kilogram per day subcutaneously. The absolute neutrophil count rose above 500/mm3 in 3 days in both cases. We believe that GM-CSF expedited the recovery of granulocyte counts in our patients and warrants further study in the management of drug induced neutropenia.

Agranulocytosis↗
PubMed1991

Mechanisms of acute pancreatitis. Vascular etiology.

Vascular mechanisms play an important but controversial role in the pathogenesis of acute pancreatitis. In experimental animals, injection of wax, powder, air, mercury, and microspheres into the pancreatic artery causes pancreatitis by end artery occlusion with resulting cellular infarction. Larger microspheres do not cause pancreatitis because collateral blood flow is preserved. Clinical evidence, such as microthrombi and atheromatous emboli in the pancreatic artery of patients with pancreatitis, supports pancreatic infarction as an etiologic agent. Experimental and clinical studies have suggested that pancreatic ischemia may also cause pancreatitis, but these studies have not been conclusive. We have compared five hours of total occlusion of the pancreaticoduodenal artery along with four hours of reperfusion to bile injection into the pancreatic duct as causes of pancreatitis. Bile injection caused a significant increase in serum amylase, activation of trypsin in pancreatic exudate, and histologic evidence of necrotizing pancreatitis. Pancreatic blood flow decreased as pancreatitis developed. Ischemia for five hours did not cause a significant increase in serum amylase or activation of trypsin in pancreatic exudate. Only edema was seen histologically, but there was no necrosis. Pancreatic blood flow increased with reperfusion. We believe ischemia aggravates, but does not initiate pancreatitis. Ischemia does not induce inflammation and necrosis in the pancreas, although infarction does.

Acute Disease↗
PubMed1991

Endoscopic evaluation of infected pancreatic necrosis.

The most severe form of acute pancreatitis is characterized by necrosis of the pancreatic parenchyma and/or peripancreatic tissue. Secondary infection of this necrotic tissue carries a high mortality because there is little limitation to the spread of this infection in the retroperitoneum. Improvements in the management of infected pancreatic necrosis have been achieved by techniques that allow complete removal of the infected debris. Problems still remain in identifying the extent of necrosis and removing all of it. Intraoperative endoscopy can be used to evaluate tracking of the infected process to other areas of the retroperitoneum. Direct visualization of the path that the necrotizing process has taken to areas of the retroperitoneum that are difficult to reach allows the dissection to be limited if there is no necrosis or expansion to remove all necrotic material completely. The endoscope can also be used to remove necrotic material either by irrigation or by direct debridement. The methodology of this technique is described.

Abdomen↗
PubMed1991

Plasma calcitonin gene-related peptide and atrial natriuretic peptide levels during resection of pheochromocytoma.

Calcitonin gene-related peptide (CGRP) and atrial natriuretic peptide (ANP) are potent hypotensive agents. To determine if they play a counterregulatory role in catecholamine excess in patients with pheochromocytoma, plasma levels were measured in four patients undergoing resection of sporadically occurring tumors. Each patient was prepared with phenoxybenzamine hydrochloride (Dibenzyline); two patients also received propranolol. Blood was obtained for plasma levels of epinephrine, norepinephrine, CGRP, and ANP at induction of anesthesia, skin incision, tumor manipulation, tumor removal, and 24 hours after operation. Baseline plasma norepinephrine and epinephrine levels were markedly elevated and increased significantly with tumor manipulation and decreased significantly 24 hours after operation. CGRP and ANP levels were slightly elevated throughout but did not change significantly with tumor manipulation or early after tumor resection. Circulating CGRP and ANP do not appear to have an acute counterregulatory role in catecholamine excess in patients with pheochromocytoma but may exert some influence on postoperative hypotension after tumor removal.

Adrenal Gland Neoplasms↗
PubMed1990

Calcitonin gene-related peptide increases coronary flow and decreases coronary resistance.

Calcitonin gene-related peptide (CGRP) is a potent vasodilator, but its effects on in situ ventricular function are unknown. We studied effects of intracoronary CGRP (100, 200, and 600 pmole/min, for 10 min) in 21 open-chest chloralose-anesthetized dogs. Systemic, pulmonary, left ventricular (LVP), central venous, and pulmonary capillary wedge pressures were continuously monitored. Left ventricular wall thickness (WT) and circumflex coronary blood flow were also measured. CGRP was infused into the proximal circumflex artery. During CGRP infusion there were no changes in heart rate, cardiac index, pulmonary artery pressure, or systemic vascular resistance, no percentage change in ventricular WT, and no changes in dWT/dt, peak dP/dt, or the slope of end-systolic points on WT/LVP loops. But there were significant changes in coronary flow (CQ), coronary resistance (CRES) and mean arterial blood pressure (MAP) from control (C)* (P less than 0.05). (table; see text) CGRP is a potent coronary artery vasodilator causing notable dose-dependent decreases in coronary resistance and a rise in myocardial flow, despite a decreased MAP (all P less than 0.05). CGRP does not affect ventricular contractility in vivo.

Animals↗
PubMed1990

Mobilization of the right lobe of the liver for right adrenalectomy.

Exposure of the right adrenal gland can be a problem with a transabdominal approach because of the overlying liver. The usual method of handling the liver to gain access to the right adrenal gland is to retract the liver superiorly and laterally, but when the right adrenal gland or tumor within it is high lying, exposure may be inadequate. In this situation, mobilization of the right lobe of the liver will provide direct access to the right adrenal gland and vein.

Adrenal Gland Neoplasms↗
PubMed1990

Echinococcal disease of the liver in pregnancy.

Although echinococcal disease of the liver is common in some parts of the world, it is rarely seen in the United States. Even from endemic areas, few reports deal with its treatment during pregnancy. A 25 year old 18 week pregnant Italian woman presented with pruritus and right upper quadrant pain. Ultrasound revealed a cystic lesion in the left lobe of the liver. The cyst was treated by operative insertion of hypertonic saline and capsulorrhaphy. The patient and her fetus had no postoperative complications. We believe that the pregnant patient with symptomatic hepatic echinococcal disease should be treated operatively and that insertion of hypertonic saline and capsulorrhaphy is the safest and most effective technique for both the mother and fetus.

Adult↗
PubMed1990

Pancreatic duct drainage in chronic pancreatitis.

Pancreatic duct drainage is an effective method of dealing with many of the surgical complications of chronic pancreatitis without sacrificing pancreatic endocrine or exocrine function. Between 65 and 90% of patients with intractable pain of chronic pancreatitis and a dilated pancreatic duct will have substantial pain relief with complete ductal drainage by a lateral pancreaticojejunostomy. The mortality of this procedure ranges from 0 to 5%. In spite of operation, late mortality of this disease remains high with 1/3 to 1/2 of patients dying within 10 years. Fixed biliary tract obstruction and upper gastrointestinal obstruction can also complicate chronic pancreatitis. We have combined drainage of the common bile duct and stomach with pancreaticojejunostomy to deal with these problems and have found no increase in morbidity or mortality. Pseudocysts occur more frequently in patients with chronic pancreatitis. We have also combined pseudocyst drainage with lateral pancreaticojejunostomy in 26 patients having both pseudocysts and chronic pancreatitis. These patients achieve the same degree of pain relief noted in patients undergoing lateral pancreaticojejunostomy alone without any increase in morbidity or mortality. Drainage procedures are safe and effective and are our preferred method of dealing with obstructive complications of chronic pancreatitis.

Cholestasis↗
PubMed1990

Are cystgastrostomy and cystjejunostomy equivalent operations for pancreatic pseudocysts?

To compare the effectiveness of cystgastrostomy and cystjejunostomy for treatment of pancreatic pseudocysts, 39 patients with cystgastrostomy were compared to 59 patients with cystjejunostomy. The groups were comparable in age, sex, cause of pancreatitis, pseudocyst location, symptoms, and preoperative serum amylase level. Cysts treated with cystgastrostomy were larger (mean diameter, 11.1 +/- 0.9 cm) than cysts treated by cystjejunostomy (mean diameter, 6.7 +/- 0.7 cm) (p less than 0.05). Mean duration of surgery was 148 +/- 11 minutes for cystgastrostomy versus 265 +/- 15 minutes for cystjejunostomy (p less than 0.05). Mean blood loss was 397 +/- 82 ml for cystgastrostomy versus 703 +/- 80 ml for cystjejunostomy (p less than 0.05) Mean intraoperative fluid requirements were 2640 +/- 313 ml for cystgastrostomy and 4403 +/- 362 ml for cystjejunostomy (p less than 0.05). Cyst recurrence was 10% for cystgastrostomy versus 7% for cystgastrostomy. Postoperative gastrointestinal bleeding occurred in 8% of patients with cystgastrostomy and in 2% of patients with cystjejunostomy. Infection problems with cystjejunostomy included two wound infections and one case of septicemia; infection problems with cystjejunostomy included five intraabdominal abscesses, two wound infections, and one case of pneumonia. Two patients died with cystgastrostomy (both from gastrointestinal bleeding); two patients died with cystjejunostomy (one from intraabdominal sepsis and one from pulmonary embolus). Cystgastrostomy was used for significantly larger pseudocysts and was associated with significantly less blood loss and operating time than cystjejunostomy (p less than 0.05). Morbidity and mortality from cystgastrostomy and cystjejunostomy were comparable, although gastrointestinal bleeding was more common with cystgastrostomy and intraabdominal abscess was more common with cystjejunostomy. Since cystgastrostomy can usually be performed more quickly and with less blood loss, it should be considered whenever anatomically feasible.

Adolescent↗
PubMed1990

Management of Cushing's syndrome secondary to adrenal adenoma during pregnancy.

This report discusses our experience with two patients who had unilateral adrenalectomy during pregnancy as treatment for Cushing's syndrome secondary to an adrenal adenoma. Previously only five patients with this clinical problem who underwent unilateral adrenalectomy during pregnancy had been reported. We have reviewed the world literature on Cushing's syndrome in pregnancy secondary to an adrenal adenoma. A total of 19 patients who had unilateral adrenalectomy for this problem after the completion of pregnancy were identified. The review of world literature and the two patients who are the subject of this report were the basis of our analysis of fetal death, neonatal complications, and maternal complications in seven pregnancies during which unilateral adrenalectomy was performed (group 1) compared to the 19 pregnancies that were associated with unilateral adrenalectomy at the completion of pregnancy (group 2). Of the seven pregnancies in group 1, one fetal death and no neonatal complications occurred, but fetal death and neonatal complications occurred in 12 of the 19 pregnancies in group 2. Four of the seven mothers in group 1 had complications; 16 of the 19 mothers in group 2 had complications. This study suggests that adrenalectomy during pregnancy should be considered as a therapeutic option in the management of Cushing's syndrome secondary to an adrenal cortical adenoma.

Adenoma↗
PubMed1990

Calcitonin gene-related peptide levels are elevated in patients with sepsis.

Calcitonin gene-related peptide (CGRP), an endogenous vasoactive peptide encoded by the calcitonin gene in nerve cells, is distributed throughout the cardiovascular system and is a potent vasodilator. Plasma levels of CGRP have been elevated in animal models with sepsis. This study was designed to determine whether plasma CGRP levels are elevated in patients with sepsis and perhaps contribute to the hyperdynamic cardiovascular state in sepsis. Plasma CGRP levels were obtained from normal healthy volunteers and from patients with sepsis. Volunteers were afebrile and had normal pulse and blood pressure. Patients with sepsis were selected according to the following criteria: (1) temperature higher than 38.5 degrees C, (2) white blood count greater than 14,000/ml, (3) positive blood culture of bacterial organisms, (4) hemodynamic parameters consistent with hyperdynamic sepsis, and (5) negative history of thyroid or other endocrine abnormalities. CGRP was extracted and assayed by radioimmunoassay for iodine 125-labeled human CGRP. In patients with sepsis, the cardiac index was 5.4 +/- 0.5 L/min/m2 (normal, 3.0); systemic vascular resistance was 7.1 +/- 0.5 mm Hg/L/min (normal, 16); oxygen delivery was 1496 +/- 137 ml/min (normal, 1000). Plasma CGRP levels were significantly elevated in the patients with sepsis, 14.9 +/- 3.2 pg/ml, compared to plasma CGRP levels in control volunteers, 2.0 +/- 0.3 pg/ml (p less than 0.0005). These elevated levels of CGRP may contribute to the decreased vascular resistance and increased cardiac output in the hyperdynamic septic state.

Adult↗
PubMed1990

Needle aspiration of nonfunctioning parathyroid cysts.

Until recently, nonfunctioning parathyroid cysts were usually identified at operation for a presumed thyroid mass. Thyroid needle biopsy now allows their preoperative diagnosis and potential definitive treatment. This study reviews four patients with nonfunctioning parathyroid cysts treated during a two-year period. Three women and one man range in age from 28 to 70 years. Each presented with an asymptomatic thyroid mass ranging from 3 to 5 cm in length. None had symptoms of primary hyperparathyroidism. Serum calciums were from 9.2 to 10.7 mg/dl and serum phosphoruses were 3.2 to 4.4 mg/dl. Needle aspiration revealed 5 to 85 cc of water-clear fluid. C-terminal parathyroid hormone in three patients was 12,600, 6,500 and 61,200 pg/ml and N-terminal PTH was 1,700 pg/ml in one. All four had normal serum calcium and phosphorus on follow-up ranging from six months to two years. Two patients had resolution of their cysts with a single aspiration. One patient had recurrence but has no evidence of recurrence six months after injection with tetracycline. Another patient had a recurrence but remains well one year following reaspiration. Nonfunctioning parathyroid cysts present as a thyroid mass. Needle aspiration of water-clear fluid high in parathormone is diagnostic and, in most patients, is the therapeutic modality of choice.

Adult↗