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In a 46-year-old man with Zollinger-Ellison syndrome, multiple imaging studies were negative for a primary gastrinoma. Preoperative endoscopic ultrasonography (EUS) revealed a 3.3-cm mass which appeared to be in the pancreatic head. During surgery, a celiac lymph node of the size of the mass seen by EUS was found, but the pancreatic head also felt firm and was suspicious for a mass. After resection of the celiac node, intraoperative EUS revealed no mass in the pancreatic head. Based upon intraoperative EUS findings, the pancreatic head was not resected. Histologic evidence of gastrinoma was found in the celiac lymph node and a 4 to 5 mm nodule in the duodenal wall. Postoperatively serum gastrin levels returned to normal.

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This study retrospectively evaluated the cost-effectiveness of laparoscopic cholecystectomy compared to open cholecystectomy in a single university-affiliated community hospital. The medical records of all patients that underwent laparoscopic cholecystectomy during 1990 and open cholecystectomy during 1989 in one hospital were reviewed. Hospital stay, hospital charges, surgeons' and anesthesiologists' fees were determined. Fifty patients from each group were contacted to determine recovery time to full activity after surgery. Those having common duct exploration and those converted to open cholecystectomy after an attempted laparoscopic cholecystectomy (n = 8) were excluded. A summary of results is included below (Table 1). In our early experience with laparoscopic cholecystectomy we found that the total charges for laparoscopic cholecystectomy were more than for open cholecystectomy when one recognizes the 1-year difference in patient accrual between the two groups. Time to full recovery was markedly reduced in patients undergoing laparoscopic cholecystectomy compared to those having an open procedure. Despite the overall increased total charge with laparoscopic cholecystectomy, the shorter recovery period allowing the patients an earlier return to full preoperative activities contributes to its cost-effectiveness when compared to open cholecystectomy. Further experience with laparoscopic cholecystectomy and refinements in management of these patients should allow for further reductions in charges for this procedure.

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Tracheal obstruction and superior vena cava (SVC) syndrome are rare complications of retrosternal goiter. These two conditions present a difficult diagnostic and therapeutic challenge. Malignancy is the most common cause of SVC syndrome. Determining whether SVC syndrome is due to a benign or malignant process is imperative before instituting treatment, but this determination may be difficult. We present a case of a patient presenting with upper airway obstruction and SVC syndrome with a large mediastinal mass. The mass was determined to be a multinodular goiter. The patient was managed by surgical removal of the goiter with complete resolution of symptoms. This case illustrates the need for careful preoperative evaluation and the importance of establishing a histologic diagnosis prior to initiating treatment for SVC syndrome.

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Cholecystectomy in the pregnant patient has been generally avoided because of the reported high incidence of associated fetal loss that has been linked to spontaneous and elective abortion during the first trimester and premature labor during the third trimester. Recent developments relating to diagnostic and anesthetic management and the use of tocolytic agents have altered the over-all approach to patients. We have, therefore, retrospectively reviewed the medical records of all women discharged from four area hospitals during 1982 to 1987 with a concurrent diagnosis of cholelithiasis and pregnancy. Twenty-two patients met the review criteria. The incidence of biliary stone disease among gravid patients during the time interval was 0.05 per cent. Of 22 patients, none underwent radiation for diagnosis. Nine patients underwent cholecystectomy while pregnant; two were operated upon during the first trimester, four during the second and three during the third. Three required common bile duct exploration and three had intraoperative cholangiograms. Elective abortion was not recommended to the six patients because of radiation exposure. Two of nine had premature contractions develop that were controlled with tocolytic agents. There were no spontaneous abortions. The mean Apgar scores for neonates born subsequent to cholecystectomy was virtually identical to neonates born to patients in whom cholecystectomy was deferred. It is concluded that the diagnosis and surgical treatment of cholelithiasis can be safely undertaken in the pregnant patient without fetal loss. Delaying appropriate surgical therapy no longer seems warranted.

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In a review of five Dayton, Ohio, area hospitals during a six-year period, seven patients who were treated for an acquired arteriovenous (A-V) fistula after cardiac catheterization were identified. Four patients had undergone cardiac studies in area hospitals, while three were studied elsewhere. The four A-V fistulas after 23,291 cardiac catheterization procedures in Dayton hospitals represented an incidence of 0.017% for this complication. Congestive heart failure and limb ischemia were the most frequent presenting symptoms that developed from two to ten months after catheterization. Intentional puncture of both the artery and vein of the ipsilateral groin for right- and left-sided heart studies was the probable cause of fistula formation in two cases. Five patients sustained inadvertent injury to both an artery and adjacent vein during percutaneous vascular access. Six A-V fistulas that involved femoral vessels were managed by division of the fistula with lateral repair of the artery and vein. An unusual communication between the right thyrocervical trunk and the internal jugular vein was handled by ligation of the affected vessels. Prompt surgical correction of this unusual complication of percutaneous vascular access is recommended as spontaneous closure is unlikely.

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The role of ammonia released by the gut on hepatic glutamine handling and metabolism was studied in postabsorptive anesthesized male Sprague-Dawley rats at spontaneous and elevated arterial glutamine concentrations. Glutamine handling and metabolite release across both organ beds were studied using arteriovenous concentration differences and simultaneously measured portal and hepatic venous plasma flows. At the spontaneous arterial glutamine load, fractional glutamine extraction, FE-Gln, by the gut and the liver was 24 and 10%, respectively. At the elevated glutamine load, gut glutamine uptake doubled, while FE-Gln remained at 24%; however, portal ammonia and alanine increased and decreased, respectively. In response, hepatic FE-Gln increased to 28% with a large release of glutamate and urea. The role of portal ammonia in modulating hepatic glutamine uptake was studied by infusing NH4HCO3 directly into the portal vein. Increasing the portal load promptly stimulated hepatic glutamine uptake and glutamate and urea release. Mitochondria isolated from these livers produced more glutamate from glutamine, suggesting ammonia activation of hepatic glutaminase flux; in addition, citrulline formation increased, suggesting a coupling of glutaminase flux to urea synthesis. The results are consistent with portal ammonia release acting as a key informational molecule in interorgan glutamine flow.

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