Risk of occult carcinomas in patients undergoing orthotopic liver transplantation for end-stage liver disease secondary to primary sclerosing cholangitis.
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Adenoma, Bile Duct↗
Biomedical subjects
R Delcore
Publications and source records attributed to R Delcore.
Bilirubin secretion as an early indicator of patient survival following orthotopic liver transplantation.
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Bile↗
Characteristics of cystic neoplasms of the pancreas and results of aggressive surgical treatment.
Twenty-one patients with pancreatic cystic neoplasms (PCNs) were treated from 1970 to 1991. Their mean age was 54 years (range: 30 to 78 years), and 15 (71%) were women. Symptoms were present for a mean of 18 months (range: 5 to 60 months) and included pain (95%), abdominal mass (52%), weight loss (38%), and jaundice (14%). Nine patients had had previous operations and were either misdiagnosed or incorrectly treated; another seven patients had preoperative misdiagnoses of pseudocysts. There were six (29%) serous cystadenomas and two (10%) mucinous cystadenomas. These were treated by excision (n = 2), distal pancreatectomy (n = 5), or pancreatoduodenectomy (n = 1). No recurrence or malignant degeneration occurred during the mean follow-up of 9 years (range: 1 to 19 years). There were 13 (62%) patients with mucinous cystadenocarcinomas. Of these 13 patients, 3 had unresectable tumors, underwent palliative procedures, and died at 4, 7, and 9 months, respectively. Ten patients underwent pancreatoduodenectomy (n = 4), distal (n = 4) pancreatectomy, or total (n = 2) pancreatectomy: 1 died of recurrence (survival: 8 months), and the remaining 9 patients had a mean survival of 6 years (range: 2 to 20 years) without recurrence. This experience suggests that patients with PCNs have a good prognosis and are curable if the cysts are diagnosed early and completely resected.
Adult↗
Diagnostic peritoneal lavage in acute peritonitis.
Fifty patients were studied prospectively to determine the value of diagnostic peritoneal lavage in the evaluation of acute peritonitis. Forty-five patients had a clinical diagnosis of acute peritonitis based on physical findings, and 5 patients were normal control subjects. All lavages were performed with an open technique in the operating room prior to laparotomy. Lavage fluid was analyzed for white and red blood cell counts, the differential, amylase, protein, bilirubin, and pH. Results were analyzed by multiple logistic regression. Thirty-two of the 45 patients with clinical peritonitis had the diagnosis confirmed at laparotomy. A white blood cell count in the lavage fluid greater than or equal to 200 cells/mm3 was associated with a 99% probability of peritonitis.
Acute Disease↗
Role of pancreatoduodenectomy in the management of primary duodenal wall gastrinomas in patients with Zollinger-Ellison syndrome.
BACKGROUND: The role of pancreatoduodenectomy in the surgical management of duodenal wall gastrinomas (DWGs) has not been well established. Recently DWGs have been recognized with increasing frequency, and several reports have emphasized that pancreatoduodenectomy can now be performed with a low operative morbidity and mortality for other conditions. The purpose of this study was to determine the indications, safety, and efficacy of pancreatoduodenectomy in the treatment of DWGs. METHODS: Forty-five patients with Zollinger-Ellison syndrome were evaluated and surgically treated between 1960 and 1991; 15 (33%) of these had primary DWGs. RESULTS: Pancreatoduodenectomy was considered necessary for curative resection in six patients. Two of these patients had multiple gastrinomas as part of multiple endocrine neoplasia type 1 syndrome and underwent tumor excisions and total gastrectomy; both died of tumor-related complications (survival, 8.5 and 12 years). A third patient did not consent to pancreatoduodenectomy, underwent total gastrectomy and tumor excision, and also died of tumor-related complications (survival, 10 years). The remaining three patients underwent pancreatoduodenectomy. After pancreatoduodenectomies were performed, these three patients became and remained eugastrinemic with normal results from secretin stimulation tests (mean follow-up, 7.5 years). CONCLUSIONS: In patients with DWGs and Zollinger-Ellison syndrome, pancreatoduodenectomy should be considered the treatment of choice whenever complete tumor excision is not possible by a lesser procedure.
Adult↗
Long-term cultured human pancreatic islets reverse hyperglycemia in diabetic nude mice.
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Animals↗
Zollinger-Ellison syndrome. A new look at regression of gastrinomas.
Of 44 patients with the Zollinger-Ellison syndrome treated at our institution, nine appeared to have undergone "regression" of their gastrinomas. Six of the nine patients had sporadic gastrinomas and became permanently eugastrinemic following excision of nodal metastases and total gastrectomy (n = 4), antrectomy (n = 1), or pancreatoduodenectomy (n = 1) (mean survival, 13 years). The other three patients had Zollinger-Ellison syndrome as part of the multiple endocrine adenopathy type 1 syndrome and became temporarily eugastrinemic after total gastrectomy (mean survival, 11 years). Occult submucosal duodenal-wall microgastrinomas (mean size, 3.0 mm) were found to have been serendipitously excised in four patients. Long-term follow-up of these nine patients, as well as of six other patients described in the literature, demonstrates that excision of occult duodenal-wall gastrinomas provides a plausible explanation for the phenomenon of apparent regression of primary gastrinomas and the eugastrinemia that may follow total gastrectomy.
Adolescent↗
Pancreaticoduodenectomy for malignant pancreatic and periampullary neoplasms in elderly patients.
Forty-two patients (age range: 70 to 86 years) underwent pancreaticoduodenectomy between 1970 and 1990 for carcinomas of the pancreas (23), ampulla (8), common bile duct (5), duodenum (5), or islet cells (1). After resection, reconstruction was done by either pancreaticojejunostomy (13) or pancreaticogastrostomy (25); four patients had total pancreatectomy. The mean duration of operation was 5 hours, the mean blood loss was 2,200 mL, the mean transfusion requirement was 4 units of blood, and mean length of hospitalization was 22 days. There were no leaks or other complications related to the pancreatic anastomoses. Six (14%) major complications occurred including two (5%) operative deaths. Mean survival was 42 months (range: 2 to 219 months) for the entire group and 35 months for patients over the age of 80. This experience suggests: (1) pancreaticoduodenectomy can be performed with low operative morbidity and mortality in elderly patients, and advanced age should not be considered a contrainindication to this potentially curative procedure; (2) pancreaticogastrostomy is a safe and easy alternate method of reconstruction; and (3) prolonged survival is possible for elderly patients following pancreaticoduodenectomy for malignant pancreatic and periampullary neoplasms.
Aged↗
Surgical options in postgastrectomy syndromes.
The various operations performed for the treatment of peptic ulcer disease can lead to a variety of iatrogenic disorders collectively referred to as the "postgastrectomy syndromes." Although the etiology of most of these disorders remains unclear, loss of vagal innervation and bypass, ablation, or destruction of the pylorus clearly are involved in the pathogenesis of most, if not all, of these disorders. Unfortunately, there often is also a poorly understood psychological element involved in the pathogenesis. Of all ulcer operations, proximal gastric vagotomy results in the fewest physiologic abnormalities and the mildest postoperative symptoms. The continued popularity of this operation should effect a marked reduction in the incidence of disabling postgastrectomy syndromes. Fortunately, symptoms severe enough to necessitate remedial operation are uncommon, and conservative medical management is always indicated and usually suffices. When disabling symptoms are refractory, a thorough evaluation of the patient and an accurate classification of the syndrome are essential to guarantee a satisfactory result from surgical intervention. Although numerous surgical procedures have been developed to deal with the different syndromes, with varied results, the Roux-en-Y procedure has emerged as the operation of choice for most, if not all, postgastrectomy syndromes. However, the Roux-en-Y procedure has not been universally successful, and this operation can itself lead to the recently recognized postgastrectomy state of Roux-en-Y stasis syndrome. Prevention therefore remains the best form of therapy, and remedial operation should not be undertaken until adequate time has elapsed since the original operation and all forms of conservative treatment have failed.
Diarrhea↗
Characteristics of duodenal wall gastrinomas.
Fifteen patients with duodenal wall gastrinomas (DWGs) and the Zollinger-Ellison syndrome have been treated since 1960. In 6 of 11 patients, DWGs were recognized at operation and totally excised. In four patients, the tumor was subsequently found in the proximal duodenum of the surgical specimens. In 12 patients, DWGs were single and lymph node metastases were present in 8. In three patients, DWGs were multiple and lymph node metastases were present in two. All DWGs were submucosal and all were located in the first or second portions of the duodenum except one found in the fourth portion. Tumor size ranged from 1 to 15 mm, and nine were less than 5 mm. Of 12 patients with single DWGs, 9 have remained eugastrinemic after resection (mean follow-up: 5.5 years). None of the patients with multiple DWGs became eugastrinemic after surgery. DWGs are characteristically single, small or microscopic, submucosal, located in the proximal duodenum, rarely metastasize to the liver, and are usually curable by surgical resection.
Duodenal Neoplasms↗
Feeding induces lipid accumulation and increased Na+ transport in in vitro Necturus antrum.
We investigated the effects of feeding on lipid accumulation and transepithelial transport using in vitro Necturus gastric antral mucosae. Antra from fed Necturi were examined for lipid accumulation using light, fluorescence, histochemical, and electron microscopy. Ussing chambers were used for measurement of potential difference (PD), transepithelial resistance (Rt), short-circuit current (Isc), and unidirectional fluxes of 22Na+ and [3H]mannitol. Light microscopy of antra from 2-day postfed animals showed many intracellular lipid granules in surface mucous epithelial cells. These granules could be distinguished from other intracellular organelles by their high affinity for osmium and the lipid fluorescent probe Nile red. Glycoprotein cytochemical staining showed these granules to be distinct from the epithelial cell mucous granules. Electron microscopy showed the lipid granules to be part of a membranous reticular network. Two-day postfed animals also had a approximately 3.5-fold increase in amiloride-sensitive Isc and PD, a decrease in Rt, and an increased luminal-to-serosal Na+ fluxes. Transepithelial [3H]mannitol fluxes were low and remained unchanged in both fasted and 2-day postfed animals. After 2 days of feeding, the PD and Isc began to decrease followed by a secondary increase in Rt. Feeding Necturi a corn oil diet did not induce the appearance of either cellular lipid or alterations in Isc but produced a transient increase in Rt. Our data show that feeding (goldfish) to Necturi causes an increase in both lipid accumulation and amiloride-sensitive Na+ transport in gastric antral cells.
Amiloride↗
Pancreatogastrostomy: a safe drainage procedure after pancreatoduodenectomy.
The purpose of this study was to evaluate the role of pancreaticogastrostomy as an alternative method of restoring pancreaticointestinal continuity after pancreaticoduodenectomy. Since 1975, 45 patients have undergone pancreaticogastrostomy after pancreaticoduodenectomy at our institution. Pancreaticoduodenectomy was performed for pancreatic carcinoma (24 patients), ampullary carcinoma (8 patients), duodenal carcinoma (4 patients), common bile duct carcinoma (4 patients), pancreatic islet cell carcinoma (1 patient), trauma (1 patient), extensive colon carcinoma (1 patient), chronic pancreatitis (1 patient), and gastroduodenal artery aneurysm (1 patient). There was one operative death, for an overall operative mortality rate of 2%, and seven patients had major postoperative complications, for an overall morbidity rate of 15%. No pancreatic anastomotic leaks or other complications related to the pancreaticogastrostomy occurred. Twenty-four patients have died of recurrent carcinoma, with a mean survival of 25 months (range, 5 to 66 months), and 20 patients are alive and well, with a mean follow-up of 27 months (range, 2 to 106 months). Eight of these patients are alive 2 or more years after operation and four do not have exocrine pancreatic insufficiency. This experience confirms that pancreaticogastrostomy is a safe method of pancreatic drainage after pancreaticoduodenectomy and suggests that it may have technical advantages and therefore merits more widespread application.
Adult↗
Primary hypercoagulable states in general and vascular surgery.
Primary hypercoagulable states are increasingly recognized as causes of venous and arterial thromboembolism in surgical patients. Herein, we describe 10 patients with this syndrome who were diagnosed during a recent 1-year period. A family history and past medical history of thromboembolism and an unusual site of thrombosis are emphasized for accurate diagnosis. Although antithrombin III deficiencies were the most common abnormality found, we describe three patients with hypofibrinolytic syndromes and increased levels of tissue plasminogen activator inhibitor. The effectiveness of anticoagulation therapy in preventing recurrent thromboembolism is stressed.
Adolescent↗
Significance of tumor spread in adenocarcinoma of the ampulla of Vater.
Twenty-eight patients with ampullary carcinoma were treated between 1965 and 1988: 22 underwent pancreaticoduodenectomy with 1 operative death (5 percent), 1 had local excision, 3 had bypass, and 2 were not explored. Of the 21 patients who survived pancreaticoduodenectomy, 4 had tumor confined to the ampulla, 7 had tumor extending into the duodenum, and 10 had tumor invasion beyond the duodenum. Nine of these patients had positive lymph nodes and 12 had negative lymph nodes. The patient who had local excision was disease-free at last follow-up 104 months postoperatively. Each of the three bypassed patients died of tumor progression within 15 months. The estimated 5-year survival rate for resected patients was 60 percent and was independently related to lymph node metastases (p = 0.031) and to tumor size (p = 0.039). This experience suggests that long-term survival is possible in patients with lymph node metastases or invasive tumors extending beyond the duodenal wall and that curative pancreaticoduodenectomy can be performed with a low operative mortality; therefore, aggressive surgical resection is recommended for all patients with ampullary carcinoma.
Adenocarcinoma↗
Effects of cations and pH on apical membrane potential of in vitro Necturus antrum.
The surface epithelial cells of the gastric mucosa transport Na+ from lumen to serosa. The first step in this process is the entry of Na+ through an amiloride-sensitive Na+ channel at the apical membrane. The exact function(s) of this Na+ transport are unknown, but it has been suggested that it might help the stomach to withstand an acid load. The present study was undertaken to examine the effects of low luminal pH and the alkali cations Li+, K+, Rb+, and Cs+ on the amiloride-sensitive Na+ permeability of the apical membrane of Necturus antral cells by measuring the changes in apical membrane voltage (Vmc) using conventional microelectrode techniques. Isosmolar replacement of luminal NaCl (pH 7.25) with LiCl caused a depolarization of the Vmc, a decrease in transepithelial resistance (Rt), and an increase in the transepithelial potential (Vmc), whereas replacement with KCl, RbCl, or CsCl caused a hyperpolarization of the Vmc, an increase in Rt, and a decrease in the Vmc. Luminal acidification from pH 7.25 to pH 3.00 caused very similar changes with all the cation solutions tested, hyperpolarizing the Vmc, increasing Rt, and reducing the Vmc to near 0 mV. Acidification of the luminal NaCl solution from pH 7.25 to pH 2.00 caused a progressive hyperpolarization of the Vmc similar to the effects seen with luminal amiloride (10(-4) M) in pH 7.25 NaCl solutions or luminal Na+-free (N-methyl-D-glucamine) Ringer at pH 7.25. These results demonstrate that 1) of the cations tested only Li+ can substitute for Na+ in maintaining the Vmc, and 2) external H ions (low luminal pH) block cation permeability of the apical membrane.
Amiloride↗
Selective surgical management of correctable hypergastrinemia.
Sixty patients with surgically correctable hypergastrinemia were treated between 1960 and 1988. Provocative testing was used when available to select appropriate operations. Sources of hypergastrinemia included antral G cell hyperplasia (AGCH) (17), pancreatic gastrinomas (14), duodenal gastrinomas (11), multiple gastrinomas in patients with type I multiple endocrine neoplasia (MEN I) (five), lymph node gastrinomas (four), and the source not found in nine patients. Eugastrinemia was achieved by resection in 17 of 17 patients with AGCH, nine of 11 patients with duodenal gastrinomas, three of four patients with lymph node gastrinomas, zero of 14 patients with pancreatic gastrinomas, zero of five patients with MEN I, and zero of nine patients in whom the source was not found. Hepatic metastases developed in 11 patients with pancreatic gastrinomas, two patients with MEN I, one patient with duodenal gastrinomas, and one patient with lymph node gastrinomas. One patient in whom the source of the hypergastrinemia was not found developed hepatic metastases, and seven required total gastrectomy. This experience suggests the following: (1) that patients with AGCH, duodenal gastrinomas, or lymph node gastrinomas can usually be rendered eugastrinemic by resection; (2) that patients with pancreatic gastrinomas, whether sporadic or familial (MEN I), are rarely cured by resection and frequently develop hepatic metastases; and (3) that patients in whom the source of the hypergastrinemia is not identified and removed frequently require total gastrectomy, but antroduodenectomy should be considered because it may uncover an occult duodenal microneurogastrinoma or may correct AGCH.
Biomarkers, Tumor↗
Outcome of lymph node involvement in patients with the Zollinger-Ellison syndrome.
Prognosis of gastrinoma patients with metastases to lymph nodes only is uncertain, and the true nature of isolated nodal gastrinomas remains controversial. The purpose of this study was to determine the outcome of such patients and whether nodal gastrinomas may occur as primary lesions. Eleven patients with nodal involvement but without hepatic metastases are reported (mean follow-up of 129 months). Primary gastrinomas were located in the duodenum in seven (Group 1) and not identified in four (Group 2). In Group 1, five patients remained eugastrinemic after excision of all gross tumors and gastrectomy (n = 4) or pancreaticoduodenectomy (n = 1), one patient had residual disease and died of other causes (survival of 88 months), and one patient had MEA-I syndrome with multiple gastrinomas (follow-up of 126 months). In Group 2, three patients became eugastrinemic after nodal excision and total gastrectomy (mean follow-up of 212 months) and may represent primary nodal gastrinomas, and in one patient, liver metastases developed and the patient died. Four deaths occurred in a 27-year period, but only one was tumor-related. There was no significant difference in 20-year survival rates between the two groups (85% vs. 75%). It is concluded that 1) lymph node gastrinomas are usually metastatic from primary duodenal lesions, 2) although rare, nodal gastrinomas may occur as primary lesions, and 3) in the absence of hepatic metastases, lymph node gastrinomas, whether primary or metastatic, have a good prognosis and should not deter aggressive surgical treatment.
Adolescent↗
Liquid chromatographic monitoring of CSF metabolites.
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3,4-Dihydroxyphenylacetic Acid↗