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Biomedical subjects

B E Stabile

Publications and source records attributed to B E Stabile.

At least 37 records · Page 2Linked to original sources
PubMed1997

Percutaneous radiologic drainage of pancreatic abscesses.

OBJECTIVE: The purpose of our study was to review and report the patient selection, techniques, and results of percutaneous drainage of pancreatic abscesses by retrospective review. MATERIALS AND METHODS: Fifty-nine patients (46 men and 13 women) with a mean age of 44 years old had 80 pancreatic abscesses that were drained percutaneously under radiologic guidance (CT, n = 77; sonography, n = 2; and fluoroscopy, n = 1). Abscesses had a wide spectrum of causes, with alcoholic pancreatitis being most common, trauma second most common, and gallstones third. Ten patients had undergone surgery for pancreatic necrosis or abscess. Patients with pancreatic pseudocysts, necrosis, or acute fluid collections were excluded from this study. RESULTS: Of the 59 patients, 51 (86%) were cured with percutaneous drainage and antibiotic therapy. Of the patients who were not cured with percutaneous drainage, seven required surgery and one underwent repeat percutaneous drainage. In the 59 patients, complications included non-life-threatening bleeding in three patients. Ten of 59 patients (17%) had fistulas that spontaneously formed into the gastrointestinal tract. The duration of catheterization ranged from 4 to 119 days, with a mean duration of 33 days. The rate of mortality at 30 days after completion of percutaneous drainage was 8% (5 of 59). CONCLUSION: Percutaneous drainage was an effective therapy for this defined group of patients with pancreatic abscesses. Factors leading to the relatively high success rate described in this study likely included selection of patients; catheters of adequate size, number, and location; careful follow-up with appropriate catheter manipulations; and an integrated, cooperative approach whereby surgeons were willing to permit drainage to effect its benefits, rather than operating prematurely.

Abscess↗
PubMed1997

Islet cell tumors.

Although quite rare, the islet cell tumors present an important challenge to the clinician because of their protean manifestations and potential lethality. Early diagnosis is essential and depends on recognition of the classic and variant clinical syndromes followed by confirmation of elevated peptide levels by radioimmunoassay. Medical control of the hormonal syndrome with agents such as diazoxide for insulinoma, omeprazole for gastrinoma, and octreotide for vipoma and glucagonoma allows an orderly and thorough investigation for associated endocrinopathies and comorbid medical conditions. Localization and staging of the tumors are important because they may be small and occult, widely metastatic, or multifocal in the context of multiple endocrine neoplasia type I (MEN I) syndrome. Computed tomography, visceral angiography, endoscopic ultrasonography, and indium-labeled octreotide scanning are the most useful preoperative imaging techniques. Surgical exploration that includes intraoperative ultrasonography remains an essential localization technique for occult tumors, particularly insulinomas and gastrinomas. For all patients other than some with advanced metastatic disease or MEN I syndrome, an aggressive surgical approach with the intent of complete and curative tumor excision is indicated. Surgical cure is possible in most insulinomas, a substantial proportion of gastrinomas, and some patients with the other more rare and malignant islet cell tumors. At present, adjuvant medical therapies for unresectable malignant disease have limited efficacy. However, a variety of newer and innovative tumor localization techniques, operative strategies, and nonoperative treatment modalities hold considerable promise for the attainment of higher cure rates and improved palliation.

Adenoma, Islet Cell↗
PubMed1997

Early computed tomography is rarely necessary in gallstone pancreatitis.

The role of early CT scanning in acute gallstone pancreatitis remains ill defined. The purpose of our study was to: 1) determine whether our previously identified admission prognostic factors for gallstone pancreatitis [white blood cell (WBC) count > or = 14.5 x 10(9)/L, blood urea nitrogen (BUN) > or = 12 mmol/L, Acute and Chronic Health Evaluation II score > or = 5, glucose > or = 150 mg/dL, and heart rate > or = 100 beats/min)] correlate with the severity of pancreatic inflammation on CT scan, and 2) to determine the utility of early CT scanning in the management of gallstone pancreatitis. Admission clinical and laboratory variables were collected prospectively. Early CT scan findings were graded using the Balthazar scoring system and subgrouped into mild-moderate (Balthazar grades A-C) or severe (grades D and E) by a radiologist blinded to the patients' clinical status. Ninety-seven patients underwent surgery during their initial hospitalization without preoperative CT scanning. Four had operative complications (4%). Forty-two patients underwent early CT scan (grade A, 19%; B, 5%; C, 21%; D, 10%; and E, 45%), but only four (all grade E) had surgery delayed because of necrotizing pancreatitis, abscess, or pseudocyst. All four had persistent abdominal pain. There was one (2.5%) operative complication in the CT group and no deaths. Admission WBC count > or = 14.5 x 10(9)/L and BUN > or = 12 mmol/L correlated with severe pancreatitis (grades D and E) on CT (P < .05). We conclude that in patients with gallstone pancreatitis, 1) admission WBC count > or = 14.5 x 10(9)/L and BUN > or = 12 mmol/L correlate with the severity of pancreatic inflammation on CT scan, and 2) CT scan findings rarely influence management decisions and CT is therefore unnecessary, except in the minority of patients with objective indications of severe or unresolving pancreatitis.

APACHE↗
PubMed1996

Cardiac assessment prior to vascular surgery: is dipyridamole-sestamibi necessary?

Dipyridamole-sestamibi (PMIBI) is recommended prior to vascular surgery in patients with > or = 1 Eagle criteria (Q waves, history of ventricular ectopy, diabetes, advanced age, and/or angina). To review our cardiac morbidity and mortality and the need for preoperative PMIBI, we reviewed 109 consecutive patients with a mean age of 59 years who underwent 145 elective major vascular procedures over a 1-year period. Seventy patients (with a mean of 0.8 Eagle criteria) underwent 92 vascular procedures without preoperative PMIBI and without coronary revascularization. Thirty-one patients (with a mean of 1.1 Eagle criteria) underwent 39 procedures without coronary revascularization following PMIBI, which showed reversible ischemia in seven and a fixed defect in 10; findings were normal in 14. Preoperative coronary bypass or angioplasty was limited to eight patients (14 procedures, mean of 1.6 Eagle criteria) who had unstable angina with (2 patients) or without (6 patients) acute myocardial infarction. There were four perioperative myocardial infarctions (2.8%), seven cardiac events overall (4.8%), and one cardiac death (0.7%). Three (43%) of the seven cardiac events occurred in patients with a normal scan or fixed defect on PMIBI imaging. In the absence of unstable angina, PMIBI had a sensitivity of only 25% and a specificity of 80% for cardiac events. We conclude that among patients without severe cardiac symptoms (1) PMIBI has a very limited ability to identify patients at risk for cardiac complications, and (2) preoperative PMIBI is neither necessary nor cost-effective.

Age Factors↗
PubMed1996

Gastric adenocarcinoma in patients 40 years of age or younger.

BACKGROUND: Gastric adenocarcinoma is considered a disease of the middle aged and elderly and has been infrequently reported in patients under 40 years of age. The purpose of this study was to determine the proportion of young patients diagnosed with gastric adenocarcinoma and to compare the demographic, clinical and pathologic features of younger and older patients with gastric adenocarcinoma. METHODS: A retrospective cohort study using tumor registry records of all patients with gastric adenocarcinoma diagnosed from 1982 through 1996 at a public teaching hospital. Demographic, clinical, and pathologic comparisons were made between patients younger than 41 years of age and race- and sex-matched older patients with gastric adenocarcinoma. RESULTS: Thirty of 203 (15%) cases of gastric adenocarcinoma were diagnosed in patients less than 41 years (range 23 to 40). Male to female ratio was 1:1. Young patients were more likely to be black (33% versus 17%, P = 0.04) Both younger and older patients presented with advanced disease, with nearly half of each group having metastases. Twelve of 29 (41%) younger patients were operated on without a histologic diagnosis of gastric adenocarcinoma in contrast to only 1 older patient (P < 0.001). One of 30 (3%) young patients is alive 39 months following gastrectomy. Twenty patients died and the remaining 9 were lost to follow-up, all with known residual or recurrent disease. Six-month survival of young patients (23%) was less than older patients (42%) (P = 0.14). Young patients were more likely to have diffuse histology (80% versus 55%, P = 0.12). Overt infection with Helicobacter pylori was uncommon in both groups. CONCLUSIONS: Young patients accounted for an unusually high proportion of patients with gastric adenocarcinoma diagnosed at our public teaching hospital. Young patients were significantly more likely to be black and less likely to have an accurate preoperative histologic diagnosis. Both young and older patients presented with advanced disease and had poor survival. Young patients were more likely to have diffuse histology and had poorer 6-month survival, suggesting a more aggressive variety of the disease in this group.

Adenocarcinoma↗
PubMed1996

Surgical management and treatment of pancreatic fistulas.

Pancreatic fistulas most commonly derive as complications of elective surgical procedures on the pancreas and as sequelae of pancreatitis or pancreatic trauma. The majority of external pancreatic fistulas can be managed nonoperatively, with an expected rate of closure exceeding 80%. Internal fistulas are somewhat less likely to close with conservative measures alone. Octreotide has been shown to significantly reduce fistula output and to hasten the closure of both internal and external pancreatic fistulas without affecting the overall rates of closure. Operative therapy is reserved for the treatment of fistulas that do not respond to conservative medical management. In randomized prospective trials, prophylactic octreotide has been shown to reduce the morbidity of elective pancreatic resections with respect to overall complication and fistula formation rates. Surgical experience and technique appear to be the most important factors in determining the overall complication rates following elective pancreatic surgery.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1996

Admission factors can predict the need for ICU monitoring in gallstone pancreatitis.

The purpose was 1) to prospectively determine the prevalence of adverse events necessitating intensive care unit (ICU) monitoring in gallstone pancreatitis (GP) and 2) To identify admission prognostic indicators that predict the need for ICU unit monitoring. Prospective laboratory data, physiologic parameters, and APACHE II scores were gathered on 102 patients with GP over 14 months. Adverse events were defined as cardiac, respiratory, or renal failure, gastrointestinal bleeding, stroke, sepsis, and necrotizing pancreatitis. Patients were divided into Group 1 (no adverse events, n=95) and Group 2 (adverse events, n=7). There were no deaths and 7 (7%) adverse events, including necrotizing pancreatitis (3), cholangitis (2), and cardiac (2). APACHE 11 > or = 5 (P < 0.005), blood urea nitrogen (BUN) > or = 12 mmol/L (P < 0.005), white blood cell count (WBC) > or = 14.5 x 10(9)/L, (P < 0.001), heart rate > or = 100 bpm (P < 0.001), and glucose > or = 150 mg/dL (P < 0.005) were each independent predictors of adverse events. The sensitivity and specificity of these criteria for predicting severe complications requiring ICU care varied from 71 to 86 per cent and 78 to 87 per cent, respectively. The prevalence of adverse events necessitating ICU care in GP patients is low. Glucose, BUN, WBC, heart rate, and APACHE II scores are independent predictors of adverse events necessitating ICU care. Single criteria predicting the need for ICU care on admission are readily available on admission.

Adolescent↗
PubMed1994

Gallstone pancreatitis. The role of preoperative endoscopic retrograde cholangiopancreatography.

OBJECTIVES: To evaluate the efficacy of endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy in patients with gallstone pancreatitis and to determine criteria predictive of common bile duct stones (CBDS). DESIGN: Retrospective chart review. PATIENTS: Seventy-one consecutive patients with gallstone pancreatitis. MAIN OUTCOME MEASURES: Identification and endoscopic management of CBDS, complications, and mortality. RESULTS: Preoperatively, ERCP revealed CBDS in seven of 22 patients and postoperatively, in five of six patients. All stones were successfully removed. Laboratory values and common bile duct dilatation on admission did not predict CBDS. Persistent hyperamylasemia (> 150 U/L) and persistent hyperbilirubinemia (> 29.07 mumol/L [1.7 mg/dL]) were associated with CBDS on ERCP or intraoperative cholangiography. All five patients with cholangitis underwent ERCP, and CBDS were found and removed in four. There were no deaths and there was a 7% complication rate. CONCLUSIONS: Gallstone pancreatitis can be effectively managed by selective ERCP, endoscopic sphincterotomy, and laparoscopic cholecystectomy. Preoperative ERCP can be restricted to patients with cholangitis, persistent hyperbilirubinemia, or persistent hyperamylasemia.

Adolescent↗
PubMed1993

Biologic behavior of sporadic gastrinoma located to the right and left of the superior mesenteric artery.

Among a series of 107 closely followed patients with gastrinoma, 60 patients with sporadic type tumors were identified and evaluated. There were 44 patients (73%) with tumors to the right of the superior mesenteric artery (SMA). Of these, 16 (36%) had extrapancreatic tumors, 28 (64%) had tumor within lymph nodes, and 9 (20%) had multiple tumors. In this group of patients, there were 19 (43%) cures, and only 9 (20%) patients had hepatic metastases. In contrast, in 16 patients (27%) with tumors to the left of the SMA, there were no extrapancreatic tumors, only 3 patients (19%) had tumor within lymph nodes, and 7 (44%) had multiple tumors. In this group, there was only one cure (6%), and nine (56%) patients had hepatic metastases. These findings suggest two distinct populations of sporadic gastrinoma, one to the right (gastrinoma triangle) and the other to the left (outside triangle) of the SMA, which appear to have different biologic behaviors. These differences may reflect divergent etiologies for these two groups of tumors.

Female↗
PubMed1993

Management of primary hyperparathyroidism.

Primary hyperparathyroidism is a common disease that can be accurately diagnosed and effectively treated in most patients. The diagnosis is established by a persistent elevation of serum calcium and parathyroid hormone and by clinical evaluation. Surgery is the appropriate treatment, and preoperative localization procedures are seldom indicated. Selected patients with mild disease may be followed by procedures devised to identify deterioration of skeletal, neurological, and renal function. The accurate diagnosis and effective treatment of primary hyperparathyroidism are rewarding clinical experiences for the endocrinologist and surgeon.

Female↗
PubMed1993

Surgical treatment of peptic ulceration.

Evidence continues to accrue that proximal gastric vagotomy is a safe and effective elective operation for duodenal ulcer. Recurrent ulceration remains the major shortcoming of the procedure but reoperation is rarely required. Laparoscopic surgery for peptic ulcer disease is rapidly evolving with anterior seromyotomy and posterior truncal vagotomy emerging as the elective procedure of choice. Perforated ulcer can also be treated by laparoscopic techniques in some cases. Hemorrhage is often amenable to initial endoscopic control measures, but when surgery is required, a definitive acid-reducing operation should be employed. Ulcerogenic drug use appears to be responsible for an increasing number of emergency interventions for life-threatening peptic ulcer complications, although simple closure of perforation due to such drugs may be sufficient surgical treatment. Long-term follow-up data suggest that there is a real risk increase for gastric remnant cancer development 20 years after partial gastrectomy for peptic ulcer but the value of regular endoscopic screening of patients at risk has not been demonstrated. The long-acting somatostatin analogue, octreotide acetate, has been shown to ameliorate the symptoms of the postoperative dumping syndrome markedly, although the mechanism of action remains largely unknown.

Follow-Up Studies↗
PubMed1992

Current surgical management of duodenal ulcers.

The optimal treatment of duodenal ulcer disease today requires familiarity with a variety of operative approaches. Experience and judgment are needed to select the best procedure for the individual patient presenting with a specific ulcer complication. Improved medical therapy has relegated surgery largely to the role of emergency life-saving intervention. Nonetheless, the goal of surgery remains cure of the ulcer diathesis with avoidance of postoperative side effects. Toward this end, proximal gastric vagotomy has proved itself to be the operation of choice, not only for intractable pain, but also for perforation and perhaps for bleeding in selected good-risk patients. Its efficacy in the treatment of obstructing duodenal ulcer has not been demonstrated. Modifications of proximal gastric vagotomy, including the use of laparoscopic techniques, are currently being evaluated in patients with intractable duodenal ulcer pain.

Duodenal Ulcer↗
PubMed1991

The impact of ulcerogenic drugs on surgery for the treatment of peptic ulcer disease.

To investigate the impact of ulcerogenic drugs on surgery for the treatment of peptic ulcer disease, we reviewed 150 surgical cases. Ulcerogenic drug use (steroids and/or nonsteroidal anti-inflammatory agents, including aspirin) increased from 15% between 1972 and 1977 to 37% between 1983 and 1988. While there was no correlation between ulcerogenic drug use and hemorrhage, obstruction, or intractable pain, 16 (52%) of the 31 perforations and 26 (38%) of the 69 emergency operations were associated with use of ulcerogenic drugs. The overall mortality rate was 11%. Death was correlated with age greater than 65 years and emergency operation, but not with ulcerogenic drug use or other variables. Of 12 patients with histories of peptic ulcer disease who were treated with ulcerogenic drugs without concomitant antiulcer prophylaxis, 11 (92%) required emergency operation to treat perforation or massive hemorrhage. Standard antiulcer medications or misoprostol should be prescribed to elderly patients and to those with histories of ulcers who require ulcerogenic drug therapy.

Adult↗
PubMed1991

Contributions of the Zollinger-Ellison syndrome.

The salient contributions of the Zollinger-Ellison syndrome have made it unique. No pancreatic endocrine tumor described before (insulinoma) or subsequently (glucagonoma, somatostatinoma, vipoma, pancreatic-polypeptidoma) has been the topic of such a variety of studies, or has been such an inspiration and rich source of new ideas for investigation and ultimate improvement in patient care.

Gastrinoma↗
PubMed1991

Therapeutic options in acute diverticulitis.

Diverticulitis is a serious intra-abdominal infection that ultimately afflicts about one in four patients having colonic diverticulosis. The illness may be indolent or fulminant, depending on the degree of colonic spillage and its containment. Most patients require hospitalization, and medical therapy suffices in about three fourths. Those who fail aggressive medical management and those with recurrent acute attacks, diffuse peritonitis, abscess, persistent obstruction, or fistulization require surgical intervention. Abdominal CT scanning has supplanted the contrast enema as the acute diagnostic procedure of choice and allows guided percutaneous drainage of large abscesses in selected cases. This approach helps realize the surgical ideal of a single elective operation without a temporary colostomy. For those patients still requiring emergency surgery, the two-stage approach employing resection of the diseased colon at the initial operation is far superior to the older three-stage approach.

Acute Disease↗