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D W Rattner

Publications and source records attributed to D W Rattner.

At least 91 records · Page 5Linked to original sources
PubMed1993

Portal vein thrombosis after elective splenectomy. An underappreciated, potentially lethal syndrome.

We describe seven cases of thrombosis of the portal and splenic vein after elective splenectomy. The diagnosis was initially unrecognized in all patients and was confused with biliary sepsis (three cases), postoperative pancreatitis (three cases), or pulmonary emboli (one case). Two patients in whom the diagnosis of portal vein thrombosis was not made within 3 days of disease onset died. In the five survivors, the diagnosis was based on clinical suspicion, confirmed with color flow Doppler ultrasonography or computed tomography with intravenous contrast material, and treated with thrombolytic agents, anticoagulants, and antibiotics. In two patients, splenic vein thrombus was visualized on initial postoperative imaging studies and the thrombus subsequently extended into the portal vein. Portal vein thrombosis should be considered in patients with fever and abdominal complaints after splenectomy. Urgent treatment with thrombolysis and anticoagulants may preserve bowel integrity and be lifesaving.

Aged↗
PubMed1993

Gut macromolecular permeability in pancreatitis correlates with severity of disease in rats.

BACKGROUND: Increased intestinal macromolecular permeability could allow absorption of substances from the bowel into the systemic circulation and contribute to multiple organ system failure. METHODS: Mild, intermediate, and severe grades of pancreatitis were induced in rats using intravenous caerulein and intraductal glycodeoxycholic acid. [14C]polyethylene glycol (molecular weight, 3350 daltons; 1.1 microCi/142 mg) was instilled into the distal duodenum. At 24 hours, the animals were killed, ascitic fluid was collected for trypsinogen activation peptide measurement, and pancreatic specimens were collected and scored for based on the degree of necrosis, inflammation, and hemorrhage. RESULTS: Gut permeability to polyethylene glycol 3350 (PEG 3350) was increased in animals with early experimental pancreatitis (5.4% +/- 1.2%, n = 20) when compared with control animals (1.8% +/- 0.2%; n = 6) (P = 0.0005). Furthermore, intestinal macromolecular permeability to PEG 3350 correlated with severity of disease as predicted by the method of induction of pancreatitis (P = 0.0003), the histological findings (P = 0.0002), and total ascitic trypsinogen activation peptides content (P = 0.029). CONCLUSIONS: Increased gut permeability in experimental pancreatitis can be correlated with pancreatitis severity.

Animals↗
PubMed1993

Hyperoncotic ultrahigh molecular weight dextran solutions reduce trypsinogen activation, prevent acinar necrosis, and lower mortality in rodent pancreatitis.

Acinar necrosis in patients with acute pancreatitis can be due to enzymatic injury, ischemia, or both. We hypothesized that novel therapy aimed at an improvement of pancreatic microcirculation early in the course of pancreatitis may reduce the lethality and acinar damage. Forty-six dextran-resistant rats received controlled intraductal infusion of glycodeoxycholic acid (10 mmol/L), followed by intravenous cerulein (5 micrograms/kg/h) for 6 hours. Beginning 30 minutes after the induction of pancreatitis, all animals were resuscitated with Ringer's lactate (RL) (8 mL/kg/h intravenously for 9 hours). In addition, they were given intra-aortic bolus infusions (2 mL/kg at 30, 60, 90, and 150 minutes) of either RL, sodium chloride (NaCl) (7.5%) and dextran 60,000 (10%) (HHS-60), NaCl (7.5%) and dextran 500,000 (10%) (HHS-500), or NaCl (0.9%) and dextran 500,000 (10%) (DEX-500). Despite high-volume fluid resuscitation in the groups that received RL and HHS-60, 70% of the animals in each of these groups died within 24 hours. In contrast, the mortality rates in the groups of animals that received HHS-500 and DEX-500 were dramatically reduced to 0% and 10%, respectively (p = 0.005, p = 0.02). Histopathologic scores for acinar necrosis were significantly lower in the group of animals that received DEX-500 (p < 0.009) compared with those that received RL and HHS-60. Finally, total amounts of trypsinogen activation peptides in ascites were significantly lower in the animals that received HHS-500 (p < 0.004) and DEX-500 (p < 0.02) compared with those that received RL and HHS-60. Rapid bolus infusion of hyperoncotic ultrahigh molecular weight dextran solution with or without hypertonic saline but not RL or hypertonic-hyperoncotic saline-dextran significantly reduced pathologic trypsinogen activation, prevented acinar necrosis, and improved survival in acute experimental pancreatitis. We speculate that a sustained improvement of pancreatic microcirculation by ultrahigh molecular weight dextran is the mechanism of action.

Animals↗
PubMed1993

Factors associated with successful laparoscopic cholecystectomy for acute cholecystitis.

OBJECTIVE: This article determined which preoperative data correlated with successful completion of a laparoscopic cholecystectomy in patients with acute cholecystitis. SUMMARY BACKGROUND DATA: Although laparoscopic cholecystectomy is the procedure of choice in chronic cholecystitis, its use in acute cholecystitis may be associated with higher costs and complication rates. It is not known which patients with acute cholecystitis are likely to require conversion to open cholecystectomy based on preoperative data or if a cooling-off period with medical therapy can diminish inflammation and increase the chance of successful laparoscopic cholecystectomy. METHODS: All laparoscopic cholecystectomies done by the authors between 10/90 and 2/92 were reviewed. Data on cases of acute cholecystitis were prospectively collected on standardized data forms. RESULTS: Twenty of 281 laparoscopic cholecystectomies were done for acute cholecystitis; 7/20 patients with acute cholecystitis required conversion to open cholecystectomy compared with 6/281 patients undergoing elective operation for chronic cholecystitis. In patients with acute cholecystitis the interval from admission to cholecystectomy in the successful cases was 0.6 days vs. 5 days in the cases requiring conversion to open cholecystectomy (p = .01). Cases requiring conversion to open cholecystectomy also had higher WBC (14.0 vs. 9.0, p < .05), alkaline phosphatase (206 vs. 81, p < .02, and APACHE II scores (10.6 vs. 5.1, p < .05). Ultrasonographic findings such as gallbladder distention, wall thickness, and pericholecystic fluid did not correlate with the success of laparoscopic cholecystectomy. Patients converted from laparoscopic to open cholecystectomy required more operating room time (120 min vs. 87 min, p < .01) and more postop hospital days (6 vs. 2, p < .001). CONCLUSIONS: Laparoscopic cholecystectomy for acute cholecystitis should be done immediately after the diagnosis is established because delaying surgery allows inflammation to become more intense, thus increasing the technical difficulty of laparoscopic cholecystectomy.

Acute Disease↗
PubMed1993

Evaluation and validation of microsphere technique for determination of pancreatic blood flow.

The purpose of this study was to evaluate the radiolabeled microsphere technique for pancreatic blood flow measurements. Using a canine model with an isolated pancreatic circulation, we assessed the shunting of 11- and 15-microns-diam microspheres in the pancreas, correlated pancreatic blood flow measurements obtained with the microsphere technique with those made with an ultrasonic flow probe, and determined the effects of high doses of microspheres on pancreatic blood flow and its measurement. Microspheres of 11 microns demonstrate significant shunting through the pancreatic microcirculation with underestimation of pancreatic blood flow of approximately 10% compared with results obtained with 15-microns microspheres. There is a close linear relationship between flow results obtained with 15-microns microspheres and with an ultrasonic flow probe for both the resting (r = 0.85) and the secretin-stimulated pancreas (r = 0.97). Left atrial injections of very large doses of 15-microns microspheres (50 x 10(6)) caused an acute transient reduction of pancreatic blood flow (to 39% of baseline flow) with a return to baseline values within 2 min. The accuracy of flow results and absence of physiological changes after repeated injections support the use of 15-microns microspheres for pancreatic blood flow measurements.

Animals↗
PubMed1993

Improvement of impaired pancreatic microcirculation by isovolemic hemodilution protects pancreatic morphology in acute biliary pancreatitis.

Impairment of the pancreatic microcirculation is a characteristic finding in experimental biliary pancreatitis. Isovolemic hemodilution with dextran 60 has been proven to maintain pancreatic capillary perfusion. To evaluate the significance of this therapeutic approach with respect to histologic changes, intravital microscopic assessment of the microcirculation was combined with a morphometric analysis of the pancreas by means of light microscopy in rabbits (n = 18). Pancreatic capillary perfusion was maintained in the rabbits subjected to hemodilution 30 minutes after the induction of pancreatitis with 54 percent of the capillaries still being perfused at 12 hours, compared with only 16 percent in the control group. The improved capillary perfusion resulted in a significant reduction of those changes considered potentially reversible (cell vacuolization and interstitial edema) that surround zones of necrosis. However, because of the early establishment of necrosis in this model, hemodilution was unsuccessful in preventing all cell death. Hemodilution can limit the progressive extension of pancreatic injury in this model of biliary pancreatitis.

Acute Disease↗
PubMed1992

Histopathologic correlates of serum amylase activity in acute experimental pancreatitis.

The association of serum amylase activity with the extent of pancreatic injury in acute pancreatitis is unclear. To clarify this relationship, we induced acute pancreatitis ranging from mild to lethal in 118 Sprague-Dawley rats (350-450 g). This was achieved by controlled intraductal infusion of low- or high-dose bile salt, with or without enterokinase, followed by intravenous cerulein or saline for 6 hr. Serum amylase was measured at baseline and 6 hr. Pancreatic histopathology was evaluated by two blinded pathologists employing total surface scoring (N = 118) and morphometric 20-field documentation (N = 22). Serum amylase correlated best with edema (r = 0.61) and fat necrosis (r = 0.58), less well with acinar necrosis (r = 0.53) and inflammation (r = 0.50), and poorly with hemorrhage (r = 0.33) and perivascular infiltrate (r = 0.31). Inasmuch as edema and fat necrosis are not important determinants of severity, these observations could explain the poor prognostic value of serum amylase activity in patients with acute pancreatitis.

Acute Disease↗
PubMed1992

Morphometric characteristics and homogeneity of a new model of acute pancreatitis in the rat.

Extreme maldistribution and immediate establishment of severe cellular injury are typical features of traditional bile salt models of acute pancreatitis; both factors complicate assessment and interpretation of therapeutic benefits in trials of experimental therapy. Even more important, both are indications not of the desired induction of pancreatitis but rather of local injury by barotrauma and noxious chemicals. This study contrasts the severity and regional variability of cellular injury in traditional high-dose bile salt models with that seen in a new preparation employing the combination of intravenous (iv) caerulein (CAE) and intraductal (id) low-dose glycodeoxycholic acid (GDOC). Thirty-six male Sprague-Dawley rats (350-450 g) were induced with (group A) high-dose GDOC id (34 mmol/L), low-dose GDOC id (10 mmol/L) (group B), or low-dose GDOC id combined with caerulein iv for 6 h (group C). The regional distribution of histopathologic injury within the pancreas was assessed in 20 fields/organ by two pathologists unaware of the induction technique used. High-dose GDOC id (group A) resulted in extremely heterogenous distribution of injury for all variables (edema, p = 0.001; acinar necrosis, p = 0.0001; inflammation, p = 0.0001; and hemorrhage p = 0.001). The lesions were confined to the head of the pancreas, which showed large areas of necrosis involving entire lobules, whereas adjacent areas were unaffected. Low-dose GDOC id (group B) was more homogenously distributed, but the injury was mild and regional variability (edema, p = 0.0001; acinar necrosis, p less than 0.04; inflammation, p = 0.0001; and hemorrhage p less than 0.05) was still demonstrable. In contrast, low-dose GDOC id combined with CAE iv (group C) produced moderately severe pancreatitis, which equally affected all areas of the gland. There were no geographical differences in acinar necrosis or inflammation. This feature of the new model provides a desirable prerequisite for accurate and reproducible assessment of histopathology in studies aimed at detecting effects of therapy. We suggest that it replace traditional id bile salt infusion models.

Acute Disease↗
PubMed1992

Early surgical débridement of symptomatic pancreatic necrosis is beneficial irrespective of infection.

In order to assess the recent trend of nonoperative management of pancreatic necrosis, we reviewed 82 variables in 73 consecutive patients with symptomatic necrotizing pancreatitis. The mortality rate for the series was 25% (18 of 73). The only preintervention variables that correlated with mortality were APACHE II score greater than 15 (p = 0.01), preintervention blood transfusion (p less than 0.001), respiratory failure (p less than 0.001), and shock (p less than 0.01). Patients who developed recurrent sepsis following the initial intervention had a significantly higher mortality rate (17 of 34) than those who did not (1 of 39) (p less than 0.001). The rate of recurrent sepsis varied widely among individual surgeons and correlated with APACHE II score. The presence of infected versus noninfected necrosis did not correlate significantly with outcome. When percutaneous radiologically guided drainage was the initial therapeutic modality (n = 6), recurrent sepsis requiring surgical drainage inevitably occurred. Patients treated with percutaneous drainage (often in combination with surgical drainage) had a longer hospital stay (82 versus 42 days, p less than 0.001), spent more days in the intensive care unit (31 versus 6 days, p less than 0.001), and required more days of total parenteral nutrition (57 versus 27 days, p less than 0.001) than those treated solely by surgical means. We conclude that aggressive initial surgical débridement should be the first step in managing symptomatic pancreatic necrosis and that the presence of infection should not be the sole determinant of intervention.

Bacterial Infections↗
PubMed1992

Trypsinogen-activation peptides in experimental rat pancreatitis: prognostic implications and histopathologic correlates.

Intrapancreatic activation of trypsinogens is believed to occur either as a cause or a consequence of acute pancreatitis and to be associated with the more severe forms of the disease. Trypsinogen-activation peptides (TAPs) were measured in plasma, urine, and ascites of rats (n = 54) assigned to different pancreatitis-inducing regimens reproducing the entire spectrum of severity. Compared with survivors, nonsurvivors at 9 hours had significantly higher TAP levels in plasma at 3 hours (P = 0.0001), urine (peak, 1-4 hours) (P = 0.004), and ascites (P = 0.0001) after death. Stepwise discriminant analysis showed that TAP in urine and plasma were the most accurate predictors of outcome (88.2% of animals) compared with other routine laboratory parameters. Morphometric analysis showed that the best histopathologic correlates of TAP elevation were acinar necrosis and intrapancreatic hemorrhage. In a second series of experiments using a homogeneous technique of induction producing pancreatitis with a mortality of 55% at 48 hours, plasma TAP level at 3 hours (cutoff, 0.5 nmol/L) and/or urinary TAP level (peak, 1-6 hours; cutoff, 25 nmol/L) accurately predicted outcome in 85% of animals. It is concluded that the TAP assay gives an accurate early prediction of outcome in different pancreatitis models and correlates best with acinar necrosis and hemorrhage.

Acute Disease↗
PubMed1992

A better model of acute pancreatitis for evaluating therapy.

Existing models of acute pancreatitis have limitations to studying novel therapy. Whereas some produce mild self-limited pancreatitis, others result in sudden necrotizing injury. The authors developed an improved model providing homogeneous moderately severe injury by superimposing secretory hyperstimulation on minimal intraductal bile acid exposure. Sprague-Dawley rats (n = 231) received low-pressure intraductal glycodeoxycholic acid (GDOC) at very low (5 or 10 mmol/L) concentrations followed by intravenous cerulein. Cerulein or GDOC alone caused only very mild inflammation. However, GDOC combined with cerulein was uniformly associated with more edema (p less than 0.0005), acinar necrosis (p less than 0.01), inflammation (p less than 0.006), and hemorrhage (p less than 0.01). Pancreatic injury was further increased and death was potentiated by increasing volume and duration of intraductal low-dose GDOC infusion. There was significant morphologic progression between 6 and 24 hours. The authors conclude that (1) combining minimal intraductal bile acid exposure with intravenous hyperstimulation produces homogeneous pancreatitis of intermediate severity that can be modulated at will; (2) the injury is progressive over at least 24 hours with finite mortality rate; (3) the model provides superior opportunity to study innovative therapy.

Acute Disease↗
PubMed1992

Fulminant peptic ulcer disease in cardiac surgical patients: pathogenesis, prevention, and management.

OBJECTIVES: To identify pathogenetic factors associated with the development of peptic ulcers in patients following cardiac surgery and to examine the efficacy of medical and surgical therapy of peptic ulcers in this setting. DESIGN: Retrospective study with randomly selected case controls. SETTING: University hospital referral practice. PATIENTS: A total of 9,199 consecutive patients undergoing procedures requiring cardiopulmonary bypass between January 1, 1980 through September 30, 1988, were reviewed. Life-threatening ulcer complications were defined as hemorrhage of greater than 2 units of packed red blood cells which prompted subspecialty consultation and required a therapeutic intervention. Patients who developed life-threatening complications of peptic ulcers (32/9199, 0.35%) (group 1) were compared with 32 randomly selected patients (group 2) for differences in potential pathogenetic factors and outcome. MAIN OUTCOME MEASURES: Gastrointestinal hemorrhage, perforated ulcers, death. RESULTS: Patients in group 1 were significantly older than patients in group 2 (66.7 +/- 7.9 vs. 54 +/- 10 yrs, p less than .01). Complications following cardiopulmonary bypass requiring further surgery or causing prolonged hypotension were significantly more frequent in patients with ulcers than in controls (10/32 vs. 1/32, p less than .005). The mortality rate for patients in group 1 was 34.3% (11/32) compared with 0% in group 2 (p less than .001). Perioperative ulcer prophylaxis was employed with equal frequency in groups 1 and 2 and did not correlate with outcome. CONCLUSIONS: The development of complications of postoperative peptic ulcers following cardiac surgery correlates with age, need for reoperation, and hypoperfusion, but not with the use of prophylactic regimens to suppress acid secretion. These results suggest that impairment of gastric and duodenal mucosal defense mechanisms is a critical factor in the development of postoperative peptic ulcers.

Aged↗
PubMed1992

Generation and possible significance of trypsinogen activation peptides in experimental acute pancreatitis in the rat.

Trypsinogen activation peptides (TAP) were quantified by radioimmunoassay in blood, urine, and peritoneal exudate of rats with experimental pancreatitis. Forty-four animals were studied, comprising a control group and four different induction techniques (cerulein, cerulein plus either 2- or 10-min intraductal glycodeoxycholic acid [GDOC] infusion, and cerulein plus intraductal GDOC with enterokinase [EK]). Significantly higher TAP concentrations were found at 6 h (or at death) in plasma and ascites of all pancreatitis groups compared with controls. TAP quantitation in hourly urine samples demonstrated significantly higher concentrations from the third hour onward in the most severe groups and from the fourth hour onward in the cerulein-treated rats. All nonsurviving rats had a plasma TAP of greater than 2.5 nM/L, whereas only 1 of 34 surviving animals had such a concentration (p less than 0.001). A significant stepwise increase in total TAP in ascites was found when comparing the cerulein group, the two GDOC groups, and the EK group (p less than 0.001). Chromatography of samples with a high TAP content demonstrated comigration with synthetic TAP. We conclude that free TAP are present in blood, urine, and peritoneal exudate of rats with experimental pancreatitis of different pathogenesis and that the amount of TAP may be indicative of the severity of the disease process.

Acute Disease↗
PubMed1992

Acute complicated pancreatitis: redefining the role of interventional radiology.

Computed tomographic (CT) scans in 30 patients who had undergone percutaneous drainage for acute complicated pancreatitis were retrospectively studied to determine the role of percutaneous drainage. Fifty-nine collections were percutaneously drained in these 30 patients. Eighty-one catheters were placed in the 59 collections (average, 1.4 catheters per patient). Patients required an average of three catheter manipulations, seven abdominal CT scans, 5 weeks of catheter drainage, a mean hospital stay of 82 days (range, 42-122 days), and a mean intensive care unit stay of 31 days (range, 1-62 days). Percutaneous intervention was successful in 14 patients, partially successful in four, and unsuccessful in eight. A temporizing effect was seen in four patients. Percutaneous intervention was successful in one of 10 central (pancreas and lesser sac areas) collections and 28 of 49 peripheral collections. Surgical debridement was necessary in 16 patients because of failed or incomplete percutaneous drainage. Complications occurred in five patients, and the mortality rate was 33%. Drainage of central areas should initially be performed by a surgeon, while peripheral collections should be drained percutaneously as they develop.

Acute Disease↗
PubMed1992

Bile duct injury in laparoscopic cholecystectomy.

Bile duct injury is an unusual complication of laparoscopic cholecystectomy. Although the exact incidence is yet to be determined, it does appear to be more common than bile duct injury during open cholecystectomy. Previous publications have attempted to document the incidence of bile duct injuries and methods to prevent it. We reviewed our experience with 11 bile duct injuries from laparoscopic cholecystectomy. Such injuries were manifested by abdominal pain, low-grade fever, and hyperbilirubinemia or biliary fistula. These patients' injuries were treated by using drainage or reexploration and ligation of cystic duct and subcholecystic duct leaks and Roux-en-Y hepaticojejunostomy for common duct strictures and lacerations.

Adult↗
PubMed1992

Ciliated enteric duplication cyst presenting as a pancreatic cystic neoplasm: report of a case with cyst fluid analysis.

Pancreatic cysts include inflammatory pseudocysts, cystic tumors (serous and mucinous), and various rare cystic lesions. We report a case of a ciliated enteric duplication cyst that presented on computed tomographic scan as a pancreatic cystic neoplasm. Cyst fluid analysis revealed markedly increased concentrations of carcinoembryonic antigen and CA 125 and increased fluid viscosity. These features are typical for a mucinous cystic neoplasm of the pancreas and demonstrate a potential pitfall associated with the diagnosis of pancreatic cysts by chemical analyses. Enteric duplications involving the pancreas are rare, usually of gastric origin, and usually communicate with their enteric source. Morphological and histochemical analysis suggest that this cyst was of caudal foregut origin. This is the first reported case of a ciliated foregut cyst involving the pancreas. The chemical characteristics of the cyst fluid of these lesions have not been described previously.

Aged↗