Search PubMed⌕ Search

Biomedical subjects

D W Rattner

Publications and source records attributed to D W Rattner.

At least 109 records · Page 6Linked to original sources
PubMed1991

Risk factors for pancreatic cellular injury after cardiopulmonary bypass.

BACKGROUND: Pancreatitis is a known complication of cardiac surgery with cardiopulmonary bypass. Although ischemia is believed to be a factor, the cause of pancreatitis after cardiopulmonary bypass remains unknown. METHODS: We prospectively studied 300 consecutive patients undergoing cardiac surgery with cardiopulmonary bypass. Serum amylase, pancreatic isoamylase, and serum lipase were measured on postoperative days 1,2,3,7, and 10. Pancreatic cellular injury was defined as the presence of hyperamylasemia (greater than 123 U per liter) with an increase in either the serum level of lipase (greater than 24 U per liter) or the peak level of pancreatic isoamylase. Trypsinogen-activation peptides, which indicate intrapancreatic enzyme activation, were measured in the urine of the last 101 patients studied. RESULTS: Evidence of pancreatic cellular injury was detected in 80 patients (27 percent), of whom 23 had associated abdominal signs or symptoms and 3 had severe pancreatitis (2 with pancreatic abscess and 1 with necrotizing hemorrhagic pancreatitis). Two of 19 postoperative deaths were secondary to pancreatitis. In multivariate analyses, the development of pancreatic cellular injury was significantly associated with preoperative renal insufficiency, valve surgery, postoperative hypotension, and perioperative administration of calcium chloride. The administration of more than 800 mg of calcium chloride per square meter of body-surface area was an independent predictor of pancreatic cellular injury, and the increase in risk was dose-related. No differences were found in the level of trypsinogen-activation peptides between patients who had pancreatic cellular injury and those who did not. CONCLUSIONS: Pancreatic cellular injury, as indicated by hyperamylasemia of pancreatic origin, is common after cardiac surgery. The administration of large doses of calcium chloride is an independent predictor of pancreatic cellular injury and may be a cause of it.

Aged↗
PubMed1991

New laser delivery device for laparoscopic procedures.

A new device to facilitate laser delivery and improve mechanical advantage during surgical procedures is described. In the device, a quartz fiber is used to transmit laser energy to a forked metal tip. The utility of the device was assessed in five pigs. In three pigs a laparoscopic cholecystectomy was performed and in two pigs a laparoscopic lymph node dissection was performed. Advantages of the device included reduced smoke, clearer dissection planes, tactile feedback, and excellent mechanical advantage when used for blunt dissection. The device was qualitatively superior to both sculpted tip quartz fibers and electrocautery.

Animals↗
PubMed1991

Adverse effect of therapeutic vasoconstrictors in experimental acute pancreatitis.

Alpha-adrenergic drugs commonly are used to treat hypotension resulting from severe acute pancreatitis. It was shown previously that although systemic arterial pressure is increased by phenylephrine, pancreatic microcirculatory perfusion is decreased. Because inadequate tissue perfusion may be critical in the progression of edematous pancreatitis to parenchymal necrosis, it was hypothesized that vasoconstrictors might be harmful in pancreatitis. Therefore the effect of phenylephrine on cerulein-induced mild pancreatitis were studied. Sprague-Dawley rats (n = 54) were randomly allocated to 6 experimental groups and subjected to the following infusion regimens: (1) cerulein (cae) + phenylephrine (phe), (2) cae + saline (NS), (3) NS + phe, (4) cae + phenoxybenzamine (pbz) + phe, (5) NS + pbz + phe, and (6) NS. Initial and terminal hematocrit, serum amylase activity, and blood ionized calcium concentration were determined. The animals were killed 9 hours after starting the infusion. Macroscopic and histologic changes were scored by a 'blinded' pathologist. Phenylephrine increased the severity of cerulein-induced pancreatitis as manifested by statistically significant adverse changes in serum amylase, hematocrit, ionized calcium, peripancreatitic soap formation, and acinar cell vacuolization. These changes were antagonized by alpha-adrenergic receptor blockade with phenoxybenzamine. It is concluded that phenylephrine is deleterious in acute experimental pancreatitis, the first demonstration of such an effect by a pharmacologic vasoconstrictor, and suggested that microcirculatory changes may be important in the transition of mild to severe pancreatitis. Caution in the use of vasoconstrictor drugs in patients with acute pancreatitis is recommended.

Acute Disease↗
PubMed1991

Laparoscopic cholecystectomy: evolution, early results, and impact on nonsurgical gallstone therapies.

Laparoscopic cholecystectomy, a surgical technique first performed in France, has gained widespread acceptance among surgeons in the United States. The abdominal cavity is inflated by carbon dioxide, a video monitor is inserted via a laparoscope placed periumbilically, and the gallbladder is freed and removed from the liver bed by using small subcostal ports for access and dissection. Intraoperative cholangiography is routinely performed, but uncertainty exists about how best to manage choledocholithiasis. Compared with traditional cholecystectomy, initial reports describing laparoscopic cholecystectomy cite shorter recovery times because no large incisions are made, thus potentially reducing the cost and morbidity of cholecystectomy. A survey of 614 early cases supports these claims, with a reported complication rate of 1.5% and quick resumption of normal activities by patients. Because of its promise for reduced morbidity, laparoscopic cholecystectomy is challenging open cholecystectomy as the therapeutic gold standard for symptomatic cholelithiasis. Thus, the standard to which the nonsurgical gallstone therapies, such as lithotripsy and contact dissolution, will be compared may shift to laparoscopic cholecystectomy. As the laparoscopic complications are similar to those of traditional cholecystectomy, such as abscesses and bile leaks, their percutaneous treatment should not change.

Cholecystectomy↗
PubMed1991

Continuous complete collection of uncontaminated urine in conscious rodents.

We describe a novel technique for complete and continuous bladder urine collection in conscious unrestrained rats. After urethral ligation, a silastic catheter is placed through a flexible steel tether, tunneled subcutaneously from the posterior neck area to a suprapubic incision, and inserted and fixed into the exposed urinary bladder. The catheter drains by gravity into a dependent collecting vessel protected from contamination by feces or food.

Animals↗
PubMed1991

The effect of size of giant pancreatic pseudocysts on the outcome of internal drainage procedures.

Pancreatic pseudocysts (PP) that fail to resolve spontaneously are optimally treated by internal drainage to a viscus. Pseudocysts adherent to the stomach are usually drained by way of cystgastrostomy. Recent experience with giant pseudocysts (greater than 15 centimeters), however, challenges this approach. Fifty-two patients with pancreatic pseudocysts of various sizes were treated from 1982 to 1986 at the Massachusetts General Hospital. Twenty-eight PP were suitable for internal drainage. The postoperative complication rate was directly proportional to the size of the pseudocyst. Four patients had giant PP, three of which occurred after an attack of acute pancreatitis. All four were treated by cystgastrostomy. Three of four patients with giant pseudocysts had life-threatening postoperative complications as a result of incomplete emptying of the cyst, and two patients died. No evidence of anastomotic leakage could be demonstrated by upper gastrointestinal series or computed tomographic scans. Transgastric drainage tubes in these three instances were not protective. We conclude that cystgastrostomy may not be appropriate for the treatment of giant pancreatic pseudocysts because it fails to provide dependent drainage of a large cyst cavity. If internal drainage is performed, the cyst should be anastomosed to a defunctionalized loop of jejunum in a dependent position. In some instances, external drainage of giant pancreatic pseudocysts may be safer than cystgastrostomy.

Adolescent↗
PubMed1990

Hypocalcemia in experimental pancreatitis occurs independently of changes in serum nonesterified fatty acid levels.

Hypocalcemia and lipid abnormalities commonly occur in acute pancreatitis. Experimentally, increased plasma concentrations of free fatty acids (NEFA) can lower the serum calcium (Ca). We hypothesized that changes in blood-ionized calcium might parallel changes in NEFA concentration in pancreatitis. This hypothesis was tested in a model of severe necrotizing pancreatitis and a model of mild edematous pancreatitis. Adult male Sprague-Dawley rats (300-400 g) were randomized to receive: 100 microL sodium glycodeoxycholic acid (GDOC 34 mmol/L) infused into the pancreatic duct to produce severe necrotizing pancreatitis (Group 1); 100 microL 0.9% NaCl (NS) infused into the pancreatic duct (Group 2); Sham laparotomy (Group 3); A 6 h IV infusion of cerulein (5 mucg/kg/h) to produce mild edematous pancreatitis (Group 4); and a 6 h IV infusion of NS (Group 5). A significant time dependent decrease in blood-ionized Ca concentration, compared to normal rats, was observed in both GDOC-pancreatitis (0.836 +/- .057 vs 1.069 +/- .038 mmol/L p less than 0.001) and cerulein pancreatitis (0.988 +/- .028 vs 1.069 +/- .038 p less than 0.05), which was maximal 24 h after induction of pancreatitis. The degree of hypocalcemia correlated with the severity of pancreatitis (GDOC 0.836 +/- .057 vs cerulein 0.988 +/- .028 p less than .001). Hypocalcemia was not observed in any of the control groups. All experimental and control groups had significantly increased baseline NEFA concentrations compared with normal rats (p less than 0.001); however, no further increase in NEFA concentration occurred in conjunction with the observed time-dependent decline in ionized calcium concentrations. Although the NEFA concentrations observed in these experiments were comparable to those measured in human acute pancreatitis (exclusive of hyperlipemic pancreatitis), the time course of the changes suggests that increases in serum NEFA concentrations in experimental pancreatitis are not the primary factor mediating hypocalcemia.

Acute Disease↗
PubMed1990

Giant cell tumor of the pancreas of mixed osteoclastic and pleomorphic cell type: evidence for a histogenetic relationship and mesenchymal differentiation.

We describe a giant cell tumor of the pancreas composed of a mixture of osteoclastic and pleomorphic cell types. This rare tumor had a unique immunohistochemical profile. Both types of tumor giant cells stained for vimentin, alpha-1-antitrypsin, alpha-1-antichymotrypsin, synaptophysin, muscle actin, and neuron-specific enolase, but not for epithelial markers. Electron microscopy showed cells which resembled primitive fibroblasts and osteoclast with no epithelial features. These findings are most consistent with mesenchymal differentiation. The extensive homologies in immunohistochemical staining of both osteoclastic and pleomorphic giant cells in this case indicates that these cells are histogenetically related.

Carcinoma↗
PubMed1989

Bacterial infection is not necessary for lethal necrotizing pancreatitis in mice.

Sepsis is the most common cause of late death in pancreatitis. The presence of early bacterial infection has been correlated with the severity of the disease. A choline-deficient ethionine-supplemented (CDE) diet given to young female mice produces severe necrotizing pancreatitis that has morphologic and biochemical similarities to the human disease. We therefore searched for bacterial pancreatic infection in female CD-1 mice given the CDE diet. The mortality rate was 47.5% in mice fed the CDE diet. All of these mice had severe pancreatitis with inflammation, edema, and necrosis on histologic examination. Bacterial infection was present in 1/12 pancreatica among nonsurvivors and in 1/32 pancreatica in surviving animals (p not significant). Histologic examination showed edema to be more pronounced in surviving mice, although the overall severity of morphologic changes was not significantly different between survivors and nonsurvivors. We conclude that bacterial infection is not a determinant of the severity or lethality of experimental pancreatitis induced by the CDE diet.

Acute Disease↗
PubMed1989

Hyperamylasemia after cardiac surgery. Incidence, significance, and management.

The significance of hyperamylasemia and its relationship to pancreatitis after cardiac surgery is controversial. Three hundred consecutive patients undergoing cardiopulmonary bypass were prospectively studied to determine the incidence and significance of postoperative hyperamylasemia. Ninety-six of three hundred patients (32%) developed hyperamylasemia. Fifty-six patients (19%) were classified as having isolated hyperamylasemia because they were asymptomatic and had normal serum lipase. Thirty-two patients (10.7%) had subclinical pancreatitis defined as elevation of serum amylase and lipase or pancreatic isoamylase. Many of these patients had mild gastrointestinal symptoms that were self-limited. Eight patients (2.7%) had overt pancreatitis documented by clinical findings, biochemical abnormalities, and computed tomography (CT) scan or autopsy. Isoamylase analysis demonstrated that isolated hyperamylasemia usually originated from nonpancreatic sources. However, hyperamylasemia occurring in conjunction with abdominal signs and symptoms or elevated serum lipase was almost always pancreatic in origin. Patients with hyperamylasemia had a significantly higher mortality rate (seven of 96 patients, 7.5%) than those with normal serum amylase (two of 204 patients, 0.9%) (p less than 0.01) even when the amylase was nonpancreatic in origin (five of 56 patients, 9%). The reason that nonpancreatic hyperamylasemia is associated with increased postoperative mortality is not established but may represent a variety of metabolic aberrations or tissue injuries. It is concluded that 1) hyperamylasemia after cardiopulmonary bypass is a marker of potential clinical importance, and 2) pancreatitis in this setting is more common than previously recognized and is a potentially lethal complications. Successful treatment depends on early diagnosis and aggressive treatment.

Acute Disease↗
PubMed1989

Gastrocutaneous fistulas associated with pancreatic abscesses. An aggressive entity.

Previous reports of gastrocutaneous fistulas emphasize their benign nature and the probability of spontaneous healing without the need for surgical closure. In distinct contrast we report our experiences with six patients whose gastrocutaneous fistulas were caused by fulminant pancreatitis and pancreatic abscesses. High-output acid fistulas appeared days to weeks after drainage of left upper quadrant-infected collections. None occurred at the time of initial abscess drainage. Most originated high on the greater curvature of the stomach and traversed the abscess cavity. Three of six patients had previous splenectomies, but these operations were remote in time from the appearance of the fistula. Nonoperative management was successful in only two of six patients. Massive hemorrhage from the fistula tract contributed to the deaths of three patients. The pathogenesis of these fistulas appears to be consequent to gastric injury resulting from adjacent pancreatic inflammation. We conclude that (1) gastrocutaneous fistulas associated with pancreatitis are unlikely to heal even with drainage of the abscesses and are often complicated by hemorrhage, (2) surgical closure of the fistula will often be necessary and should not be unreasonably delayed, and (3) when performed in a semi-elective setting, resection of the damaged gastric segment, perhaps with an omental or serosal patch to buttress the gastric suture line, has a good chance of success.

Abscess↗
PubMed1988

Surgical intervention in acute pancreatitis.

There is no one operative treatment for acute pancreatitis. Surgery is indicated to resolve diagnostic uncertainty and perhaps to modify the early course of gallstone pancreatitis. Peritoneal lavage is useful in reversing early-phase systemic circulatory effects mediated by toxins in the ascitic fluid, but does not modify the underlying pancreatitis. When pancreatitis progresses to pancreatic and peripancreatic necrosis, the ultimate outcome is determined by a) the amount of necrosis, b) the extent of extrapancreatic necrosis, and c) bacterial contamination of necrosis. The amount of pancreatic regional necrosis that can be safely observed for healing is unknown; large collections tend to become infected secondarily and thus should be evacuated. Computed tomographic scanning is the best current means of detecting pancreatic necrosis and abscesses. Only percutaneous aspiration can reliably differentiate sterile from infected collections. As sepsis is the most common cause of death in acute pancreatitis, adequate surgical drainage is essential, while antibiotic therapy is only adjunctive. Aggressive treatment directed at the two principal causes of death, early-phase shock and late-phase sepsis, should reduce mortality to about 1% overall and to about 5% in cases complicated by regional necrosis and sepsis.

Abscess↗
PubMed1985

A rapid method for culturing guinea pig gastric mucous cell monolayers.

A method has been developed for growing confluent primary cultured monolayers of guinea pig gastric mucous cells suitable for in vitro electrophysiological, transport, and pharmacological studies. Isolated mucous cells were enriched on a one-step Percoll density gradient and plated on fibronectin-coated plastic dishes or in small cups with holes containing glutaraldehyde-fixed Vitrogen gels. These cups were designed to fit in Ussing chambers. Mucous cells attached, proliferated, and formed confluent monolayers in 3 d. The low cuboidal cells contained periodic acid Schiff-positive mucous granules that were negative by Bowie and indirect immunofluorescent staining for pepsinogen. Electron microscopy revealed polarized mucous cells with microvilli, mucous granules, microfilaments, small mitochondria, some vacuoles, and junctional complexes that excluded wheat germ agglutinin-peroxidase. No basal lamina was present. Monolayers could be maintained for over 2 wk but subcultures were not made. The cultures were virtually free of fibroblasts. Epithelial sheets produced by this simple and rapid method can be used for electrophysiological, ion transport, and pharmacological studies.

Animals↗
PubMed1985

Recurrent hyperparathyroidism due to implantation of parathyroid tissue.

Recurrence of hyperparathyroidism after initially successful primary operation is usually caused by inadequate resection of diseased tissue or recurrent carcinoma. Since it is known that normal parathyroid tissue may be autotransplanted into a muscle bed, it is plausible that inadvertent implantation of parathyroid tissue spilled at operation may occur. In four of 23 reoperations for hyperparathyroidism in an 11 year period, we found evidence that iatrogenic parathyroid implantation had occurred. Two of the four patients had multiple parathyroid implants in the previous operative field, and one of these patients had documented spillage of a cystic adenoma during the original operation. Another two of the four patients were found to have recurrent adenomas containing suture material at sites of previous excision of the adenomas. No patient had gross or histologic evidence of parathyroid carcinoma. We conclude that inadvertently spilled parathyroid tissue may implant in the neck or mediastinum and cause persistent or recurrent hypercalcemia. Therefore, all efforts should be made to handle the parathyroid glands only by their pedicles and not to crush, suture, or violate the capsule. Needle aspiration of parathyroid cysts could lead to implantation along the needle tract.

Adenoma↗
PubMed1985

Timing of surgical drainage for pancreatic pseudocyst. Clinical and chemical criteria.

Traditional concepts of managing pancreatic pseudocysts have changed with the advent of computerized tomography (CT) and ultrasound scanning, but new misconceptions related to spontaneous resolution have replaced some old ones. This report shows a difference in natural history and treatment requirements when pseudocysts are associated with acute versus chronic pancreatitis. There were 42 consecutive patients with pseudocysts treated over 5 years. Thirty-one were known alcoholics, two had gallstone pancreatitis, and nine had idiopathic pancreatitis. An attack of acute pancreatitis was identifiable within 2 months preceding in 22 patients, but there were only chronic symptoms in 20. Spontaneous resolution of the pseudocyst occurred in three patients (7%), all of whom had recent acute idiopathic pancreatitis, normal serum amylase levels, and pancreatograms showing normal pancreatic ducts freely communicating with the pseudocyst. Factors associated with failure to resolve included known chronic pancreatitis, pancreatic duct changes of chronic pancreatitis, persistence greater than 6 weeks, and thick walls (when seen) on scan. Nearly all (18/19) patients with known chronic pancreatitis had successful internal drainage of the pseudocysts immediately upon admission, whereas 6/20 patients with antecedent acute pancreatitis were found to require external drainage at the time surgery was eventually elected. Isoamylase analysis, performed on serum from 19 patients by means of polyacrylamide gel electrophoresis, detected the abnormal pancreatic isoamylase pattern described as "old amylase" in 15. When old amylase was present in the serum, internal drainage was always possible (14/14). In four of five patients whose serum contained no detectable old amylase, internal drainage was not possible regardless of the length of prior observation. There were four nonfatal complications arising from an acute pseudocyst during the wait for maturity. It is concluded that prolonged waiting is expensive and unnecessary for pseudocysts in chronic pancreatitis when there has been no recent acute attack. However, pseudocysts developing after identifiable acute pancreatitis should be observed in the safety of a hospital for up to 6 weeks to allow for either spontaneous resolution or maturation of the cyst wall. The appearance of old amylase in the serum suggests that the pseudocyst wall has achieved sufficient maturity to allow safe internal anastomosis.

Adult↗
PubMed1983

Abnormalities of the pancreatic and biliary ducts in adult patients with choledochal cysts.

A choledochal cyst in the adult patient is not just an aneurysmal dilatation of the common bile duct, but it is the most obvious manifestation of a more widespread pancreaticobiliary ductal dysplasia. Most patients have abnormalities of the pancreatic ducts and, frequently, multiple areas of dilatation involving the intrahepatic bile ducts. Of our nine patients, six had pancreatograms, five of which were distinctly abnormal. Two of the five had recurrent pancreatitis. Six patients were found to have marked stenosis of the outflow tract from the cyst. Because the mucosa lining the choledochal cyst was chronically ulcerated, anastomoses to the cyst formed strictures in seven (64%) of 11 patients, and the long-term risk of carcinoma arising in the cyst was increased. The preferred therapy was excision of the cyst with Roux-en-Y hepaticojejunostomy.

Adolescent↗