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Biomedical subjects

B J Ammori

Publications and source records attributed to B J Ammori.

At least 19 recordsLinked to original sources
PubMed2005

Therapeutic, prophylactic, and preresection applications of laparoscopic gastric and biliary bypass for patients with periampullary malignancy.

BACKGROUND: Laparoscopic bypass surgery for the palliation of gastric and biliary obstruction is associated with a rapid recovery. This study aimed to extend its application to other aspects in the management of patients with periampullary cancer. METHODS: Between 2001 and 2004, 21 patients (median age, 68 years) underwent laparoscopic gastric (n = 8), biliary (n = 5), and combined gastric and biliary (n = 8) bypass. In addition to its therapeutic role (n = 12), indications included a concomitant prophylactic gastric (n = 3) and biliary (n = 2) bypass as well as pre- 1 Whipple's relief of deep jaundice at the time of staging laparoscopy (n = 3). Construction of the biliary bypass to the gallbladder (n = 11) or bile duct (n = 2) was based on preoperative imaging. RESULTS: All procedures were completed laparoscopically. The median operating times for gastric, biliary, and combined bypass were 75, 60, and 130 min, respectively. The addition of a prophylactic bypass did not significantly prolong the operating time, as compared with a single therapeutic bypass. One patient died postoperatively of aspiration pneumonia. The postoperative hospital stay (median, 4 days) was not significantly influenced by the type of bypass. No recurrence of or new obstructive symptoms developed during the follow-up period after a therapeutic or prophylactic bypass. CONCLUSIONS: Applications of laparoscopic gastric and biliary bypass can safely be expanded to include a prophylactic role and preresection relief of obstructive jaundice. Prophylactic bypass surgery does not prolong operating time or hospital stay significantly and prevents future onset of obstructive symptoms.

Adult↗
PubMed2004

Laparoscopic hand-assisted pancreaticoduodenectomy: initial UK experience.

BACKGROUND: By and large, the limited world experience with laparoscopic pancreaticoduodenectomy (PD) has been unfavorable, but the laparoscopic hand-assisted approach to PD has recently shown promising results. We report the first successful UK experience with laparoscopic hand-assisted PD (LHAPD). METHODS: A 62-year-old man who presented with painless obstructive jaundice was found at endoscopy, to have an ampullary tumor. Preoperative biopsy specimens confirmed the diagnosis of an adenocarcinoma, and CT showed no evidence of either vascular involvement or metastatic disease. A staging laparoscopy showed no intraabdominal metastases, and an LHAPD was performed using a Gelport. RESULTS: The intraoperative course was uneventful. Two units of blood were transfused intraoperatively, but no postoperative blood transfusion was required. The operative time was 11 h (plus a 30-min break). The patients postoperative recovery was uneventful except for superficial pressure sores over the buttocks and elbows. The patient resumed oral fluid and dietary intake on the 1st and 3rd postoperative days, respectively, and was discharged from hospital on the 9th postoperative day. Histology demonstrated an ampullary adenocarcinoma with clear resection margins and involvement of two of the 13 lymph nodes examined. At 2-month follow-up, the patient remains well and is receiving adjuvant chemotherapy. CONCLUSIONS: LHAPD achieves good oncological clearance and can be performed safely in selected patients. The early promising results with this approach will undoubtedly encourage wider adoption of this procedure and are likely to widen the selection criteria.

Adenocarcinoma↗
PubMed2003

Concomitant laparoscopic gastric and biliary bypass and bilateral thoracoscopic splanchnotomy: the full package of minimally invasive palliation for pancreatic cancer.

INTRODUCTION: Pancreatic cancer is unresectable in 80% or more of patients. Biliary and duodenal obstruction and intractable abdominal and back pain are the most common complications of the disease. These complications may be palliated effectively using minimally invasive techniques. Their combined application in a single setting is presented and discussed in this article. CASE REPORT: A 59-year-old man with a locally advanced carcinoma of the head of the pancreas presented with obstructive jaundice and intractable pain requiring opiate analgesia. An attempt at endoscopic biliary stenting was unsuccessful, and a percutaneous biopsy was deemed unsafe. Preoperative magnetic resonance cholangiography showed cystic duct insertion abutting the upper limit of the biliary stricture. A laparoscopic Roux-en-Y hepaticojejunostomy, prophylactic loop gastroenterostomy, and tumor biopsy were combined with a bilateral thoracoscopic splanchnotomy. RESULT: Surgery and subsequent recovery were uneventful, and the patient was discharged from hospital on the fourth postoperative day off opiates. He remained free of jaundice and severe pain, until 6 months later, when he represented with jaundice, cachexia, and proximal small bowel obstruction secondary to multiple liver and peritoneal metastases. He underwent further palliative laparoscopic enteric bypass with resolution of the intestinal obstruction, but died of the disease 10 days later. CONCLUSION: Laparoscopic gastric and biliary bypass and bilateral thoracoscopic splanchnotomy may be safely combined to provide an effective comprehensive minimally invasive palliation of incurable pancreatic cancer.

Anastomosis, Roux-en-Y↗
PubMed2003

Perianal abscess due to Neisseria gonorrhoeae: an unusual case in the post-antibiotic era.

Described here is the case of a 21-year-old homosexual male patient who presented with perianal abscess without urethritis that was caused by infection with Neisseria gonorrhoeae. Incision and drainage of the abscess and oral penicillin therapy resulted in full healing, without the development of an anal fistula. The spectrum of gonococcal abscesses and the relevant aspects of their management are discussed.

Abscess↗
PubMed2003

Laparoscopic reduction of an ileoileal intussusception and resection of an inverted Meckel's diverticulum in an adult.

Intussusception occurs commonly in children, but rarely is observed in adults. Whereas the hydrostatic pressure of a contrast enema often proves diagnostic as well as therapeutic in infants and children, resection usually is required for an underlying bowel pathology in older children and adults. Conventionally, the resection is accomplished at laparotomy. We report the case of a 20-year-old woman who presented with diarrhea and vomiting of 1 week duration. She was found unexpectedly to have intussusception on abdominal ultrasonography. The intussusception was laparoscopically reduced, and a segment of the middle small bowel that harbored an inverted Meckel's diverticulum was resected laparoscopically, after which an intracorporeal anastomosis was fashioned. The ileus resolved on postoperative day 4, and the patient was discharged from hospital on postoperative day 5. The role of the laparoscopic approach in the management of intussusception is discussed.

Adult↗
PubMed2003

Staged and complete laparoscopic management of cholelithiasis in a patient with gallstone ileus and bile duct calculi.

BACKGROUND: Gallstone ileus is an uncommon cause of small bowel obstruction, and its incidence peaks in elderly women. Although enterolithotomy has been accomplished laparoscopically, often using a laparoscopically assisted approach, controversy persists as to the indication, timing, and surgical approach to a cholecystectomy with closure of the cholecystoduodenal fistula. METHODS: We present the case of a 63-year-old woman with symptomatic cholecystolithiasis who presented with acute gallstone ileus and underwent an emergency laparoscopic enterolithotomy. Hypotonic duodenography during the follow-up period demonstrated a cholecystoduodenal fistula and previously unsuspected stones in the bile duct. The patient underwent an elective laparoscopic cholecystectomy with repair of the fistula, a concomitant bile duct exploration, choledocholithotomy, and primary bile duct closure. RESULTS: The patient enjoyed an uneventful recovery, and was discharged home on postoperative day 5 after her initial emergency surgery. Her recovery after the subsequent elective surgery was more expeditious, with a discharge from hospital on postoperative day 2 and a return to office employment 2 weeks later. CONCLUSION: In the good-risk patient, staged laparoscopic management of gallstone ileus and the associated cholecystoduodenal fistula is feasible and appears to be safe. In such patients, imaging of the biliary tree is essential to detect silent choledocholithiasis, which also may be managed concomitantly and safely by the laparoscopic approach.

Cholecystectomy, Laparoscopic↗
PubMed2003

Laparoscopic cholecystectomy: are patients with biliary pancreatitis at increased operative risk?

BACKGROUND: Previous reports of laparoscopic cholecystectomy (LC) in patients with biliary pancreatitis suggested increased operative difficulty, high rates of conversion, and greater morbidity and mortality. METHODS: Between 1990 and 1997, LC was performed for biliary pancreatitis in 63 patients (Group I) and for other causes in 829 patients (Group II). RESULTS: Patients with biliary pancreatitis were significantly older (median age 57 vs 50 years, p = 0.009), with greater co-morbidity (ASA III/IV 24% vs 11%, p = 0.008). The groups were comparable with respect to the frequency of previous abdominal operations, acute inflammation of the gallbladder, and the frequency of bile duct calculi detected by intraoperative cholangiography. Moderate to severe adhesions involving the gallbladder were significantly more frequent in patients with biliary pancreatitis (46% vs 29%, p = 0.004). No significant differences were observed between the two groups with respect to intraoperative (1.5% Group I vs 6.0% Group II, p = 0.109) or postoperative complications (10% vs 8%, p = 0.426), conversion rate (0 vs 2.7%, p = 0.181), or duration of operation (median 92 vs 85 min, p = 0.33). CONCLUSION: Despite increased age and co-morbidity and more frequent adhesions, our data showed no evidence that intraoperative or postoperative complications were more frequent in patients with biliary pancreatitis than in other patients undergoing LC.

Acute Disease↗
PubMed2003

Calcitonin precursors in the prediction of severity of acute pancreatitis on the day of admission.

BACKGROUND: Calcitonin precursors are sensitive markers of inflammation and infection. The aim of this study was to evaluate the role of plasma calcitonin precursor levels on the day of admission in the prediction of severity of acute pancreatitis, and to compare this with the Acute Physiology And Chronic Health Evaluation (APACHE) II scoring system. METHODS: Plasma concentrations of calcitonin precursors were determined on admission in 69 patients with acute pancreatitis. APACHE II scores were calculated on admission. Attacks were classified as mild (n = 55) or severe (n = 14) according to the Atlanta criteria. Plasma calcitonin precursor levels were determined with a sensitive radioimmunoassay. RESULTS: On the day of hospital admission, plasma levels of calcitonin precursors were significantly greater in patients with a severe attack compared with levels in those with a mild attack of pancreatitis (median 64 versus 25 fmol/ml; P = 0.014), but the APACHE II scores were no different (median 9 versus 8; P = 0.2). The sensitivity, specificity, positive predictive and negative predictive values, and accuracy for the prediction of severe acute pancreatitis were 67, 89, 57, 93 and 85 per cent respectively for plasma calcitonin precursor levels higher than 48 fmol/ml, and 69, 45, 23, 86 and 50 per cent respectively for an APACHE II score greater than 7. Differences in the specificity and accuracy of the two prognostic indicators were significant (P < 0.001 and P = 0.001 respectively). A plasma calcitonin precursor concentration of more than 160 fmol/ml on admission was highly accurate (94 per cent) in predicting the development of septic complications and death. CONCLUSION: The assay of plasma calcitonin precursors on the day of admission to hospital has the potential to provide a more accurate prediction of the severity of acute pancreatitis than the APACHE II scoring system.

APACHE↗
PubMed2003

Laparoscopic removal of a large gastric bezoar in a mentally retarded patient with pica.

Whereas small gastric bezoars may be removed endoscopically, large bezoars traditionally are removed at laparotomy. We describe a 33-year-old mentally retarded woman with pica syndrome who had experienced episodes of upper abdominal pain and distension of 10 months duration. Gastroscopy showed a large bezoar in the stomach, and attempted endoscopic removal was unsuccessful. The patient underwent laparoscopic extraction of the bezoar, which proved to be an ingested glove. She made an uneventful recovery and was discharged home on postoperative day 1. She had no wound complications, and her symptoms had not recurred at a 3-month follow up assessment. The operative technique is described, and the merits of the laparoscopic approach are discussed.

Adult↗
PubMed2003

"Semi-open" blunt primary access to the abdominal cavity during laparoscopic surgery: a new technique.

BACKGROUND: Despite major technologic advances in laparoscopic surgery, the creation of the pneumoperitoneum remains a critical step and is associated with a recognized incidence of complications. The aim of this study was to evaluate the safety and feasibility of a new "semi-open" blunt technique for primary cannulation of the abdominal cavity in patients undergoing laparoscopic surgery. METHODS: Between October 2000 and November 2001, 300 patients underwent laparoscopic surgery under the care of one surgeon. Surgery was elective in 158 patients and urgent/emergent in 142 patients. The semi-open blunt technique for primary cannulation of the peritoneal cavity was applied in 241 (80%) of the patients and was periumbilical in most cases. A closed blunt technique was applied in 48 (16%) of the patients, and the Veress needle was used in 11 (4%) of the patients. RESULTS: The semi-open blunt technique for primary cannulation of the abdominal cavity successfully achieved access in all patients in whom it was attempted. Minor live injuries occurred in two patients (one with the semi-open method and one with the Veress needle). No port site incisional hernias were encountered during a median follow-up of 6 months. CONCLUSIONS: The semi-open blunt technique of primary cannulation of the peritoneal cavity achieves rapid, safe, and successful access to the abdomen for laparoscopy. It is associated with minimal periportal gas leakage and port dislodgement and is an alternative method for primary cannulation.

Abdominal Cavity↗
PubMed2003

The early increase in intestinal permeability and systemic endotoxin exposure in patients with severe acute pancreatitis is not associated with systemic bacterial translocation: molecular investigation of microbial DNA in the blood.

INTRODUCTION: Sepsis is the main cause of late mortality in patients with severe acute pancreatitis and is largely attributed to secondary infection of pancreatic necrosis with gram-negative enteric organisms. This is commonly preceded by a significant increase in intestinal colonization with such microbes and with early increases in intestinal permeability, thus suggesting a mechanism of bacterial translocation. Whilst cultures of blood specimens from these patients often remain sterile, it is conceivable that bacteria might translocate in small volumes with detrimental effects but elude detection by standard microbial culture techniques. AIMS: To investigate the incidence and frequency with which bacterial DNA may exist in the systemic circulation of patients with acute pancreatitis and to relate that to disease severity, changes in intestinal permeability, and systemic endotoxin exposure. METHODOLOGY: Blood samples were obtained at admission and on days 3 and 7 from 26 patients with acute pancreatitis (seven with severe cases) and from 10 healthy controls for DNA extraction and standard microbial cultures. Polymerase chain reaction techniques were used to amplify a gene region (16S ribosomal RNA) found in all bacteria. Levels of serum endotoxin and antibodies to endotoxin core (EndoCAb) were measured at admission, and intestinal permeability to the macromolecule polyethylene glycol 3350 was determined within 72 hours of the onset of symptoms. RESULTS: Blood cultures yielded and enterococci for one patient with a severe attack and coagulase-negative staphylococci for another patient with a mild attack. No bacterial DNA was found in any of the samples. Endotoxemia was detected in 20 patients (five with severe cases), and levels of serum IgM EndoCAb were depleted in patients with severe attacks but remained relatively unchanged during mild attacks (p = 0.033). Intestinal permeability was significantly increased in patients with severe attacks of acute pancreatitis but remained unchanged during mild attacks (p < 0.05). CONCLUSIONS: Whilst severe attacks of acute pancreatitis are associated with early derangement in gut barrier function and systemic endotoxin translocation, there is no molecular evidence for associated bacterial "translocation."

Acute Disease↗
PubMed2003

The biochemical detection of biliary etiology of acute pancreatitis on admission: a revisit in the modern era of biliary imaging.

INTRODUCTION: Compared with traditional radiologic methods for the detection of cholelithiasis, early transient hypertransaminasemia had provided a useful prediction of biliary etiology in patients with acute pancreatitis. AIM: To investigate whether this application remains valid in the modern era of imaging for microlithiasis. METHODOLOGY: The biochemical detection (LFT) of cholelithiasis was based on an increase in serum alanine transaminase of >or=80 IU/L (normal range, 0-45 IU/L) within 24 hours of admission. We have taken the collective findings of abdominal ultrasound (USS), endoscopic ultrasound (EUS), and postmortem examination to represent the denominator for the diagnosis of cholelithiasis against which comparison with LFT was made. RESULTS: Of 68 patients with acute pancreatitis who were treated between October 2000 and December 2001, cholelithiasis was the etiological factor in 44 patients (65%). EUS detected microlithiasis in 5 of 10 patients examined. The etiology remained idiopathic in 3 patients (4.4%). The sensitivity, specificity, and positive and negative predictive values for USS were 86%, 100%, 100%, and 80% respectively; for LFT, they were 91%, 100%, 100%, and 86%; and for USS and LFT combined, they were 98%, 100%, 100%, and 96%, respectively. CONCLUSIONS: In patients with acute pancreatitis, the biochemical analysis within 24 hours of admission provided a simple, rapid, and more accurate prediction of cholelithiasis than USS. The combination of LFT and USS detected or excluded a biliary etiology in almost all patients.

Acute Disease↗
PubMed2003

Hypocalcemia in patients with acute pancreatitis: a putative role for systemic endotoxin exposure.

INTRODUCTION: Hypocalcemia is not uncommon during acute pancreatitis and is associated with a poor outcome. Whilst the mechanisms responsible for its development remain unclear, there is evidence to implicate endotoxemia in other models of sepsis. AIM: To investigate the potential role of systemic endotoxin exposure in the development of hypocalcemia in patients with acute pancreatitis. METHODOLOGY: Adjusted serum calcium was measured daily, and the lowest value within 72 hours of admission for acute pancreatitis was determined. Serum endotoxin and both IgG and IgM antiendotoxin core antibodies (EndoCAbs) were measured on admission. Attacks were classified as mild (n = 51) or severe (n = 21) according to the criteria of the Atlanta International Symposium of 1992. RESULTS: Hypocalcemia was significantly more frequent (86% versus 39%, p < 0.001) and reached significantly lower levels during severe attacks than during mild attacks (median [interquartile range], 2.06 [1.78-2.17] mmol/L, versus 2.23 [2.15-2.30] mmol/L; p < 0.001). Endotoxemia was present in a significantly greater proportion of patients with severe disease (71% versus 41%; p = 0.037), and serum IgM and IgG EndoCAbs were significantly depleted during severe attacks in comparison with mild attacks (p = 0.007 and p = 0.039, respectively). A negative and significant correlation was observed between endotoxemia and both the admission and lowest serum concentrations of adjusted calcium (r = -0.424 and p = 0.022; r = -0.383 and p = 0.037, respectively), and the latter correlated significantly with serum IgG EndoCAb concentrations (r = 0.251; p = 0.036). CONCLUSION: Systemic endotoxin exposure appears to play a significant role in the development of hypocalcemia in patients with acute pancreatitis.

Acute Disease↗
PubMed2003

Calcitonin precursors: early markers of gut barrier dysfunction in patients with acute pancreatitis.

BACKGROUND: Severe acute pancreatitis is associated with an early increase in intestinal permeability and endotoxemia. Endotoxin is a potent stimulator for the production and release of procalcitonin and its components (calcitonin precursors; [CTpr]). The aim of this study is to evaluate the role of plasma CTpr as an early marker for gut barrier dysfunction in patients with acute pancreatitis. METHODS: Intestinal permeability to macromolecules (polyethylene glycol 3350), serum endotoxin and antiendotoxin core antibodies, plasma CTpr, and serum C-reactive protein (CRP) were measured on admission in 60 patients with acute pancreatitis. Attacks were classified as mild (n = 48) or severe (n = 12) according to the Atlanta criteria. RESULTS: Compared with mild attacks of acute pancreatitis, severe attacks were significantly associated with an increase in intestinal permeability index (median: 0.02 vs. 0.006, P < 0.001), the frequency of endotoxemia (73% vs. 41%, P = 0.04), and the extent of depletion of serum IgM antiendotoxin antibodies (median: 43 MMU vs. 100 MMU, P = 0.004). Plasma CTpr levels were significantly elevated in patients with severe attacks compared with mild attacks on both the day of admission and on day 3 (median: 64 vs. 22 fmol/mL, P = 0.03; and 90 vs. 29 fmol/mL, P = 0.003 respectively). A positive and significant correlation was observed between the admission serum endotoxin and plasma CTpr levels on admission (r = 0.7, P < 0.0001) and on day 3 (r = 0.96, P < 0.0001), and between plasma CTpr on day 7 and the intestinal permeability index (r = 0.85, P = 0.0001). In contrast, only a weak positive correlation was observed between peak serum levels of CRP and plasma CTpr on admission (r = 0.3, P = 0.017) and on day 7 (r = 0.471, P = 0.049), as well as between CRP and each of the admission serum endotoxin (r = 0.3, P = 0.03) and the intestinal permeability index (r = 0.375, P = 0.007). CONCLUSIONS: In patients with acute pancreatitis, plasma concentrations of CTpr appear to reflect more closely the derangement in gut barrier function rather than the extent of systemic inflammation.

Acute Disease↗