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Glucagonoma is a relatively rare pancreatic islet cell tumor. Historically, these tumors present a typical constellation of symptoms including diabetes, weight loss, anemia, necrolytic migratory erythematous rash, and propensity for thrombosis. This clinical presentation is described as the glucagonoma syndrome. The syndrome can be confirmed with the use of serum measurements of glucagon levels and immunohistochemical assay of the tumor. Variations from the classic syndrome have been described, and serum measurements of glucagon in patients with suspected islet cell tumors can identify subsets of patients with glucagonoma who do not exhibit the classic syndrome. In our case, the unusual presentation of glucagonoma included the previously unreported component of an intravascular venous extension of tumor.

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UNLABELLED: The ability of 99mTc-pertechnetate/sestamibi subtraction, double-phase 99mTc-sestamibi and 99mTc-sestamibi SPECT imaging to localize abnormal parathyroid tissue was compared. METHODS: Fifty-five consecutive patients had parathyroid imaging before surgery for hyperparathyroidism. Imaging consisted of 99mTc-pertechnetate pinhole images of the neck followed by 99mTc-sestamibi pinhole images of the neck and parallel-hole images of the neck and chest (early images). Within 2.5-4.0 hr later pinhole images of the neck, parallel-hole and SPECT images of the neck and chest were obtained (late images). Nodular foci of increased sestamibi activity were considered abnormal. RESULTS: The sensitivity for abnormal parathyroid glands by visual comparison of early images and pertechnetate images was 72%-75%, late images and pertechnetate images was 73%-78% and double-phase (early and late) sestamibi images was 62%-65%; computer subtraction of pertechnetate from early images was 71%-74%; and SPECT imaging was 79%. The sensitivity for parathyroid adenomas was 89%-98%, while the sensitivity for hyperplastic parathyroid glands was only 47%-58%. CONCLUSION: Late imaging, computer subtraction and SPECT may not be necessary since they provided only marginal improvements on visual comparison of early sestamibi with pertechnetate images. Double-phase sestamibi imaging was less sensitive, so baseline thyroid imaging with pertechnetate is recommended.

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The Staphylococcus aureus pckA gene was identified and characterized. A pckA mutant lacked detectable phosphoenolpyruvate carboxykinase activity and grew poorly in the absence of glucose. Both enzymatic activity and pckA promoter activity in wild-type cells grown in the absence of glucose were at least 22-fold greater than activities in cells grown in the presence of glucose.

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OBJECTIVE: Planned perioperative endoscopic retrograde cholangiography (ERC) and sphincterotomy (ES) for suspected or proven common bile duct stones (CBDS) has been attempted in 63 of 540 consecutive patients undergoing laparoscopic cholecystectomy (LC). Experience with this intervention has been studied with respect to accuracy, efficacy, and safety. SUMMARY BACKGROUND DATA: The optimal management of CBDSs in the era of LC is not defined. Methods exist for the laparoscopic manipulation of the common bile duct; however, experience is limited. Until surgeons become comfortable with this more demanding technique, ERC and ES will have a prominent role in the perioperative management of CBDSs. METHODS: A preoperative group (n = 41) included all candidates for LC with historical, biochemical, or radiologic evidence of CBDSs. A postoperative LC group (n = 22) included patients with stones diagnosed by intraoperative cholangiogram (IOC) (n = 6) or with signs or symptoms of retained, but unproven, CBDSs (n = 16). RESULTS: Thirty-six (88%) of the preoperative attempts were successful. Stones were identified in 18 cases and ES and duct clearance were achieved in all 18. In the postoperative group, ERC was successful in 21 (95%) cases. Calculi were demonstrated in 5 of 6 patients with a positive IOC and 6 of 16 with clinically suspected retained stones. ES and duct clearance were achieved in all 11 patients with documented CBDSs. Overall, ERC was accomplished in 90% of cases. Stones were identified in 51% of cases and all stones were cleared by ES. Morbidity was confined to four cases of self-limited pancreatitis (6%). There were no deaths. CONCLUSIONS: The perioperative management of CBDSs is an appealing approach for patients anticipating the benefits of LC, at least until the laparoscopic manipulation of the common bile duct becomes a more widely accepted technique.

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The capability of performing major abdominal surgery while avoiding a large abdominal incision has clear benefits for patient care. Laparoscopic cholecystectomy can reduce hospital stays and the length of the recovery period, as well as decrease postoperative pain, diminish scarring, and provide significant cost savings.

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One hundred sixty-five operative cholangiograms were attempted in 364 patients who underwent laparoscopic cholecystectomy (45%). Laparoscopic cholangiography was successful in 150 of 165 attempts (91%). Eighty-nine per cent of studies were normal (134/150) and 11% were abnormal (16/150). All 134 patients with normal cholangiograms remained asymptomatic (false-negative rate, 0%). False-positive studies occurred in 3 of 150 (2%) total cholangiograms and 3 of 12 (25%) abnormal cholangiograms consistent with choledocholithiasis. A total of 16 of 364 patients had proven common bile duct stones (4.4%). Eight of the sixteen stones were removed by preoperative endoscopic retrograde cholangiopancreatography/sphincterotomy. Five of sixteen stones were found at cholangiography, four of which were unsuspected (4/150, 2.6%). Retained common duct stones were found in 3 of 214 patients not undergoing cholangiography (1.4%). No complications or deaths occurred that were due to cholangiography. One biliary injury occurred (1/364, 0.3%), in a patient with aberrant anatomy who did not undergo cholangiography. Laparoscopic cholangiography is a safe technique with a success rate greater than 90%. Routine cholangiography is presently recommended for prevention of biliary injury, detection of stones in the cystic and common ducts, and for training purposes, especially during the learning phase of laparoscopic cholecystectomy.

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Three hundred seventy-five consecutive patients underwent laparoscopic cholecystectomy from September 1989 to January 1991. Three hundred forty-one (91%) presented on an elective basis, and the remaining 34 patients (9%) were admitted for acute cholecystitis (24), gallstone pancreatitis (9), and cholangitis (1). Of the 375 patients, 20 were converted to laparotomy and cholecystectomy, for an overall success rate of 95% for patients undergoing laparoscopic cholecystectomy. Three hundred nineteen patients (90%) were discharged within 24 hours of surgery. Operative cholangiography was completed in 141 patients, showing choledocholithiasis in five (managed by postoperative endoscopic retrograde cholangiopancreatography [ERCP] in 4, common bile duct exploration [CBDE] in 1). Two retained stones (0.9%) were detected in 214 patients not undergoing cholangiography. Three patients (0.8%) were reoperated on because of perioperative complications. Overall morbidity for patients undergoing laparoscopic cholecystectomy was 3.5%. Major complications (0.6%) included a single common hepatic duct injury and a delayed cystic duct leak at 10 days. Minor complications occurred in 11 patients (2.9%). The single perioperative death (0.3%) was due to a myocardial infarction on postoperative day 3, after an otherwise uncomplicated laparoscopic procedure. Laparoscopic cholecystectomy appears to offer significant advantages to patient recovery, and these data suggest that it can be performed with an efficacy, morbidity rate, and mortality rate similar to those of open cholecystectomy.

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Laparoscopic cholecystectomy has rapidly emerged as a popular alternative to traditional laparotomy and cholecystectomy. Acute cholecystitis has been considered to be a relative or absolute contraindication to laparoscopic surgery. After gaining extensive experience in laparoscopic biliary tract surgery, this procedure was attempted in 15 patients with acute cholecystitis. All patients were operated on within 72 hours of admission. In five patients, the laparoscopic procedure was converted to an open laparotomy; in one patient, a localized abscess was found, and in the other four patients, extensive inflammation and edema precluded a safe dissection of the vascular and ductal structures. Laparoscopic cholangiography was performed in 14 patients and proved valuable in demonstrating the ductal anatomy. Patients were discharged an average of 2.7 days after the laparoscopic procedure. Laparoscopic cholecystectomy may be safely performed by experienced surgeons in patients with acute cholecystitis. To ensure a low complication rate, a low threshold for converting the procedure to an open laparotomy must be maintained if the ductal and vascular anatomy cannot be safely demonstrated.

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Two patients with retained laparotomy pads after laparotomy had pain, abscess formation, and bleeding, with erosion of the pad into the small bowel and colon.

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Perforation of a sigmoid diverticulum occurred in two patients in the immediate postoperative period after coronary artery surgery. Etiological factors leading to diverticular perforation after coronary artery bypass grafting are discussed. The significance of pneumoperitoneum on the postoperative chest radiograph, which prompted diagnosis in these cases, is also discussed.

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Three retrospective reviews documenting a lessened frequency of acute recurrent alcohol-induced pancreatitis following vagotomy, with or without gastrectomy or gastroenterostomy, prompted a prospective evaluation of truncal vagotomy with Bilroth II gastrectomy as a means of preventing such exacerbations. Randomization between operation and encouragement to abstain from alcohol in patients with a history of more than one, but less than ten, acute bouts of alcohol-induced pancreatitis was set by odd-even digits in the hospital number. Of 176 patients admitted with acute alcoholic pancreatitis during 23 months of study, 49 were excluded because of too few or too many prior attacks. Another 61 refused to enter the study. At least one (average 1.9) recurrence requiring hospitalization was noted in 49, or 80%, of these patients on follow-up for 2 to 26 months (average 14 months). Of the 66 who consented to participate, 33 were randomized not to undergo operation and had almost identical recurrence statistics (i.e., an average of 1.7 recurrences in 24, or 73%). By contrast, only two of 31, or six per cent, allocated to operation have experienced a recurrence (p less than 0.001). Two who had been randomized were excluded because of persisting active pancreatitis.

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Conventional removal of stones from the biliary ducts can be difficult and may result in retained stones. We developed a modified tenacious coagulum that entraps biliary duct stones, resulting in a more complete extraction. Coagulum choledocholithotomy was simplified by mixing 20 parts of cryoprecipitate with one part of 10% calcium chloride solution without thrombin. Tenacious coagula were generated that had a tensile strength of 106 to 140 g/sq cm within three to six minutes and were 106% to 300% stronger than coagula with thrombin. This technique was performed on six patients. In each case, an intact coagulum that entrapped more calculi than were seen on the cholangiogram was extracted. This modified technique is simple, safe, nontraumatic, and achieves a more complete extraction of stones.

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Fibronectin is an essential opsonin for phagocytosis of nonbacterial particulate matter by the reticuloendothelial system (RES). Fibronectin deficiency causes RES phagocytic depression and repletion of fibronectin reverses RES depression. Fibronectin depletion has been linked with multiple organ failure after surgery and trauma in patients with intra-abdominal infection. The mechanisms for fibronectin depletion have not been established. Plasma fibronectin levels were measured in 29 patients requiring operation after trauma and 15 patients undergoing elective abdominal operations. Opsonic fibronectin fell in the immediate postoperative period and on the first postoperative day in both groups. Total fluid replacement, blood loss, and operative time did not correlate with depression in fibronectin levels after trauma, although a weak correlation may exist between total fluid administration and fibronectin concentration in postoperative patients. Total fluid replacement, blood loss, and operative time may be contributing factors, but are not the major determinants of fibronectin deficiency after trauma or operation.

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Plasma fibronectin is an opsonic glycoprotein which augments reticuloendothelial phagocytic clearance of nonbacterial particulates. We evaluated the influence of intravenous infusion of plasma cryoprecipitate on circulating immunoreactive fibronectin and associated opsonic activity at 0.5, 2.0, 4.0, 10, and 21 hr postinfusion in septic (n = 8) and nonseptic (n = 6) surgical and/or trauma patients with documented plasma fibronectin deficiency. The study was a randomized, double-blind, crossover clinical protocol in which fibronectin-poor (0.116 +/- 0.025 mg/ml) cryoprecipitate extracted plasma (placebo) was compared to fibronectin-rich (2.139 +/- 0.161 mg/ml) plasma cryoprecipitate. Septic injured patients (149.37 +/- 17.11 micrograms/ml) had lower (p less than 0.05) plasma fibronectin levels than nonseptic injured patients (212.17 +/- 7.14 micrograms/ml) and both were less (p less than 0.05) than normal (330 +/- 30 micrograms/ml). As tested in vitro with a peritoneal macrophage monolayer assay, cryoprecipitate manifested opsonic activity related to its fibronectin concentration. Intravenous infusion of fibronectin rich cryoprecipitate reversed both the immunoreactive fibronectin and opsonic deficiency, while infusion of the placebo at a comparable total protein load did not reverse either deficient parameter. Reversal of fibronectin deficiency was more sustained in nonseptic injured patients as compared to septic injured patients. Thus, reversal of opsonic deficiency in septic and nonseptic injured patients is observed after infusion of plasma cryoprecipitate and not with infusion of fibronectin deficient plasma at comparable protein loads. Also, cryoprecipitate extracted plasma may serve as an appropriate control solution for randomized studies evaluating the therapeutic value of fibronectin-rich plasma cryoprecipitate.

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Plasma fibronectin deficiency and opsonic dysfunction exist in critically ill septic surgical, trauma, and burn patients with multiple organ failure. Fibronectin deficiency can be reversed by infusion of fresh plasma cryoprecipitate. The influence of therapy with human cryoprecipitate on lung vascular permeability in septic sheep with plasma fibronectin deficiency following surgery was evaluated. Additionally, selected studies on pulmonary function in septic surgical and trauma patients after infusion of plasma cryoprecipitate were completed. In patients, ventilation-perfusion balance appeared to improve as measured by the multiple inert gas elimination technique. With the lung lymph fistula preparation in fibronectin deficient sheep, infusion of human plasma cryoprecipitate (10 units; 250 ml) delayed the onset and minimized the increase in lung vascular permeability during postoperative Pseudomonas sepsis (5 X 10(9) bacteria, I.V.; 5 X 10(10) bacteria, I.P.). For example, in a first group of sheep, the transvascular protein clearance (TPC) at 2 hrs in septic sheep (n = 4) treated with only saline (volume control) was 20.1 +/- 3.1 ml/hr, compared to 11.23 +/- 0.83 ml/hr in the sheep (n =a 4) treated with fibronectin-rich cryoprecipitate (p less than 0.05). In a second group of sheep, cryoprecipitate depleted of fibronectin by affinity chromatography was used as the control solution. It also did not manifest this protective effect with respect to lung vascular permeability. Thus, at 2 hrs the lymph flow (Qlym) was 30.2 ml/hr and the transvascular protein clearance (TPC) was 18.0 ml/hr in septic sheep given fibronectin-deficient cryoprecipitate. In contrast, in the fibronectin-rich cryoprecipitate treated sheep, the Qlym was 14.8 ml/hr and the TPC was 8.12 ml/hr. It is suggested that fibronectin may influence lung vascular integrity during sepsis following surgery and trauma.

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The reticuloendothelial system provides host defense functions by the intravascular phagocytosis of bacteria and nonbacterial particulates. Fibronectin is opsonic for reticuloendothelial phagocytosis. Plasma fibronectin was measured before and after operation in patients with intra-abdominal infection. Preoperatively opsonic fibronectin was reduced by 39% of normal control levels in 16 patients with intra-abdominal infection. There was an even greater reduction of opsonic fibronectin after operation that was first observed in the recovery room. This deficiency persisted for the first 4 days with a tendency toward recovery of normal circulating levels by the fifth postoperative day. In contrast, patients who underwent elective major abdominal operation without infection manifested a transient opsonic fibronectin deficiency with recovery by the second and third postoperative days. Eight of 16 patients with intra-abdominal infection developed multiple organ failure. The opsonic fibronectin levels in those patients were lower than the levels in eight patients who did not develop multiple organ failure. Furthermore, there was no tendency toward recovery of normal circulating opsonic fibronectin in those patients. On all days when multiple organ failure occurred there was a marked deficiency of circulating opsonic fibronectin. We conclude that transient opsonic fibronectin deficiency occurs after major elective abdominal operation. Patients with intra-abdominal infection manifest opsonic fibronectin deficiency before operation, and further depletion of opsonic fibronectin occurs after operation. Postoperative multiple organ failure occurs only in association with severe opsonic fibronectin deficiency.

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Anuric renal failure developed in four patients in association with increased intra-abdominal pressure from postoperative hemorrhage. Polyuria and resolution of the renal failure occurred in each patient in response to operative decompression of the abdomen. Renal failure secondary to increased intra-abdominal pressure has been previously produced experimentally in dogs by the intraperitoneal installation of graded amounts of saline. This is the first report of this type of renal failure in clinical practice.

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Dopamine, ethanol, and mannitol were investigated to determine if they could increase pulmonary blood flow and oxygen delivery without significantly increasing intrapulmonary shunt. These drugs were studied in adult patients with respiratory distress following trauma, operation, or sepsis. Intravascular pressure, cardiac output, oxygen consumption and delivery, and limb blood flow and peripheral oxygen delivery were measured in all patients. Hypotensive patients received dopamine in incremental doses of 2 mu g/kg/min until either mean arterial pressure increased 15 mm Hg or heart rate increased by more than 15 beats/min. Ethanol was given as 10% ethanol in 5% dextrose at 2 ml/kg/hr. Mannitol was given as 25 gm of a 25% solution in a single bolus followed by infusion of 8 to 25 gm of 20% solution (mean 10 +/- 2 gm) as a continuous intravenous drip over 1 hour. No drug produced a significant change in intrapulmonary shunt. Ethanol produced significant (p less than 0.05) increases in cardiac index, heart rate, oxygen consumption, and oxygen delivery. Dopamine significantly decreased pulmonary vascular resistance while increasing systemic blood pressure. Visceral blood flow apparently increased while the peripheral vascular response to ischemia remained intact. Mannitol increased oxygen delivery and consumption in both the total body and limb. Thus in patients with adult respiratory distress syndrome (ARDS), increases in pulmonary blood flow can be achieved with several distinct pharmacologic agents without significant increases in intrapulmonary shunt. These increases in flow are generally accompanied by increases in oxygen delivery without increased pulmonary vascular resistance.

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The time course of immunoreactive and bioassayable opsonic alpha 2-SB glycoprotein (plasma fibronectin), as well as its relationship to both the extent of injury and development of postburn sepsis, was evaluated following burn injury. Immunoreactive opsonic fibronectin was depleted acutely within hours following burn; its maximal depletion occurring 12 hours postburn injury. The magnitude of depletion was correlated with the body surface area burned, and normal levels were restored at 24 hours postinjury. There was a tendency toward rebound hyperopsonemia at two weeks postburn, with a slow return to normal over the ensuing weeks. Bioassayable opsonic protein levels, in general, paralleled those of immunoreactive protein. Following restoration of opsonic protein levels, a secondary phase of opsonic fibronectin deficiency (p equal to 0.05) developed in those burn patients that became septic. Moreover, this opsonic fibronectin deficiency actually became apparent prior to the onset of clinical sepsis, although it was maximal during sepsis. The resolution of the septic episode was associated with the return of plasma opsonic fibronectin levels to normal. The possibility that secondary deficiency in immunoreactive opsonic fibronectin may be a reliable index of impending sepsis following burn warrants further investigation.

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