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Biomedical subjects

H A Pitt

Publications and source records attributed to H A Pitt.

At least 127 records · Page 7Linked to original sources
PubMed1990

Is preoperative angiography useful in patients with periampullary tumors?

Ninety patients with periampullary tumors, staged by CT scan and believed to be resectable, were staged further by visceral angiography. Most of these patients (78) had carcinoma of the head of the pancreas. Visceral angiography was normal in 62 patients. Major vessel encasement (17 patients) or occlusion (11 patients) was identified in 28 patients. There were no complications related to angiography. Among the 62 patients with normal angiograms, 48 underwent a pancreaticoduodenectomy, for a resectability rate of 77%. Among the 17 patients with vessel encasement, the resectability rate was 35%. For the 11 patients with vessel occlusion, the resectability rate was 0%. Combined with CT scan, visceral angiography is a useful adjunct in the staging of patients with periampullary tumors. Major vessel occlusion precludes resection, and major vessel encasement makes resection unlikely. If visceral angiography is normal, it is very likely that the tumor will be resectable.

Adenocarcinoma↗
PubMed1990

The triad of Streptococcus bovis bacteremia, colonic pathology, and liver disease.

The association of Streptococcus bovis endocarditis and colon carcinoma has been reported previously in small series in the medical, but not surgical, literature. Although the fecal carriage rate of S. bovis increases with colonic pathology, no explanation exists for the development of bacteremia in these cases. To explore the possible contribution of hepatic dysfunction to the development of portal and systemic bacteremia, the incidence of both colonic pathology and liver disease or dysfunction was determined in 92 patients with S. bovis endocarditis and/or bacteremia. Colonic and liver evaluation had been undertaken in 47% and 93% of patients, respectively. Among these patients, colonic pathology was identified in 51%, and liver disease or dysfunction was documented in 56%. Either the underlying colonic disease or alterations in hepatic secretion of bile salts or immunoglobulins may promote the overgrowth of S. bovis and its translocation from the intestinal lumen into the portal venous system. A compromised hepatic reticuloendothelial system may then contribute to the development of S. bovis septicemia and subsequent endocarditis. We conclude that S. bovis bacteremia is an indication to the clinician of the possibility of underlying liver disease as well as colon pathology.

Colonic Diseases↗
PubMed1990

Backscattered electron imaging and windowless energy dispersive x-ray microanalysis: a new technique for gallstone analysis.

Scanning electron microscopy with or without conventional energy dispersive x-ray microanalysis is currently used to identify gallstone microstructure and inorganic composition. Organic calcium salts are among many biliary constituents thought to have a role in gallstone nidation and growth. However, current analytical techniques which identify these salts are destructive and compromise gallstone microstructural data. We have developed a new technique for gallstone analysis which provides simultaneous structural and compositional identification of calcium salts within gallstones. Backscattered electron imaging is used to localize calcium within cholesterol at minimum concentrations of 0.01%. Windowless energy dispersive x-ray microanalysis produces elemental spectra of gallstone calcium salts which are qualitatively and quantitatively different. These combined techniques provide simultaneous structural and compositional information obtained from intact gallstone cross-sections and have been used to identify calcium salts in gallstones obtained at cholecystectomy from 106 patients.

Calcium↗
PubMed1990

Cholecystokinin prevents parenteral nutrition induced biliary sludge in humans.

Long term total parenteral nutrition (TPN) induces biliary sludge and formation of gallstones. Cholecystectomy is hazardous in these patients because of the underlying medical problems. Therefore, a randomized, double-blind controlled study was designed to test the hypothesis that daily administration of cholecystokinin-octapeptide (CCK-OP) prevents the formation of biliary sludge in humans receiving long term TPN. Adult patients receiving TPN for more than 21 consecutive days were studied. After randomization of 15 patients, the study was concluded because statistical significance was achieved. Eight patients received saline solution (placebo) intravenously and seven received CCK-OP (50 nanograms per kilogram) intravenously over a ten minute period daily. The groups were similar with respect to age, sex, diagnosis, liver function tests, amylase levels, total TPN time and time of study. All of the patients underwent weekly ultrasound studies. Volume and emptying studies of the gallbladder in response to the study drug were performed after one week. None of the patients receiving CCK-OP had sludge whereas five of eight of the patients receiving placebo had sludge (p less than 0.02). The results of emptying studies showed significant contraction of the gallbladder in those in the CCK-OP group but not in the placebo group. These data suggest that CCK-OP given intravenously daily prevents TPN induced stasis and sludge of the gallbladder. We conclude that CCK-OP should be used as routine prophylaxis against biliary sludge and formation of gallstones in patients receiving long term TPN.

Adult↗
PubMed1990

Broad spectrum penicillin as an adequate therapy for acute cholangitis.

In a previous study of patients with acute cholecystitis, we demonstrated equal efficacy with a broad spectrum penicillin (piperacillin) and a penicillin plus amino-glycoside combination. Whether a single agent broad spectrum penicillin is adequate treatment for more severe infections, such as acute cholangitis, however, is still unclear. We, therefore, conducted a three center, prospective, randomized trial to determine whether or not a broad spectrum penicillin alone is adequate therapy for patients with acute cholangitis. During a 36 month period, 96 patients with sepsis and biliary obstruction were randomly assigned to receive either piperacillin (n = 49) or ampicillin plus tobramycin (n = 47). The two groups receiving antibiotics were similar with respect to all clinical and laboratory parameters. The incidence of blood cultures with positive results (20 versus 21 per cent) and underlying malignant lesions (51 versus 62 per cent) was also similar between the two groups. The percentage of patients with a clinical cure or significant improvement was the same in the two groups (69 versus 70 per cent). However, there was a significant difference in the cure rate between patients with benign and malignant biliary obstructions (83 versus 59 per cent, p less than 0.01). No significant differences were noted between the two antibiotic groups with respect to drug toxicity, but patients with malignant conditions were more prone to antibiotic related toxicities (2 versus 19 per cent, p less than 0.05). These data suggest that outcome of treatment in patients with acute cholangitis is similar with either a broad spectrum penicillin or a penicillin plus aminoglycoside combination and is dependent upon the nature of the biliary obstruction.

Acute Disease↗
PubMed1990

Superior mesenteric vein inflow for liver transplantation when the portal vein is occluded.

An alternative solution to the problem of liver transplantation in the patient with an occluded portal vein is described. It uses a bridge graft of donor iliac vein from the superior mesenteric vein at the base of the colonic mesentery. The graft is tunnelled over the pancreas and under the stomach to the region of the liver hilum to provide portal inflow. This procedure was employed successfully in four patients, with patency for more than 2 years in the patient with the longest follow-up. By this approach it is routinely possible to perform a transplant procedure in a recipient with an occluded portal vein.

Adult↗
PubMed1989

A preliminary trial of the programmable implantable medication system for insulin delivery.

We undertook a trial to determine whether an implanted insulin-delivery system, the programmable implantable medication system (PIMS), could be used to treat patients with insulin-dependent diabetes. PIMS is a pulsatile, programmable pump with a battery life expectancy of five years. The reservoir is refilled transcutaneously every two months with a surfactant-stabilized human insulin preparation containing 400 U of insulin per milliliter. Eighteen patients received PIMS-delivered insulin for 4 to 25 months (mean, 18). The total PIMS-implantation experience comprised 28 patient-years. Good glycemic control was established and sustained during treatment (mean plasma glucose level, 7.3 mmol per liter; mean glycohemoglobin level, 8 percent [upper limit of normal, 7.5 percent]), with significantly reduced glycemic fluctuations. The total mean daily insulin dose did not change. Insulin solutions withdrawn from the pump reservoirs contained 92 percent native insulin and preserved biologic activity. There were no surgical or skin complications, severe hypoglycemic episodes, or instances of diabetic ketoacidosis. One pump was replaced because of a manufacturing defect, and four patients had catheter blockages due to omental-tissue encapsulation; two withdrew from the study and two had devices that were repaired successfully. The actuarial rate of survival of catheter function was 78 percent at 1.5 years. We conclude from this pilot study that insulin treatment with an implanted, variable-rate, programmable pump is feasible for periods up to two years.

Adult↗
PubMed1989

How many Americans will be eligible for biliary lithotripsy?

Extracorporeal shock wave lithotripsy has received increasing attention as a possible alternative to cholecystectomy. Good data, however, are not available on what percentage of the 500,000 Americans presently undergoing cholecystectomy annually might be eligible for extracorporeal shock wave lithotripsy. Therefore, we studied 100 consecutive adult patients undergoing cholecystectomy and applied present exclusion criteria to determine their suitability for extracorporeal shock wave lithotripsy. In each patient, preoperative history and operative findings were reviewed. Gallstone size and number were recorded, and cholesterol content and radiopacity were determined. Cholesterol stones were found in 74 patients, pigment stones in 21, and acalculous cholecystitis in 5. Of the 100 patients, only 19 (19%) had no exclusion criteria and, thus, would have been eligible for extracorporeal shock wave lithotripsy. These data suggest that approximately 95,000 Americans a year will be candidates for shock wave biliary lithotripsy.

Adolescent↗
PubMed1989

Surgical management of chronic intestinal pseudo-obstruction in infancy and childhood.

Chronic intestinal pseudo-obstruction is an uncommon cause of repeated obstruction in children of undetermined etiology, often leading to repeated laparotomies and early death. TPN combined with venting gastrostomy provides sufficient calories for growth and minimizes the need for operations and/or hospitalizations. Seventeen children managed with these techniques experienced a sixfold decrease in the number of hospitalizations, and more than a tenfold decrease in the number of laparotomies for obstruction compared to the period before routine use of TPN and gastrostomies. Oral feedings are encouraged whenever possible.

Age Factors↗
PubMed1989

Statement on guidelines for total parenteral nutrition. The Patient Care Committee of the American Gastroenterological Association.

This is one of a series of clinical guidelines. They represent a consensus statement dealing with optimum patient care in significant clinical areas. The statement has been prepared by the Patient Care Committee, with the advice of other experts and with peer review. As with all such guidelines, they should be interpreted in a nondogmatic manner, so as not to exclude other therapies or opinions in any particular situation. Based on present knowledge, limited at times, future modifications or other changes in these guidelines may be necessary.

Gastroenterology↗
PubMed1989

Oral calcium promotes pigment gallstone formation.

Dietary calcium supplementation has been recommended for prevention of osteoporosis and has become a standard component of most "health food" diets. Biliary calcium has been recognized to play a central role in the formation of pigment gallstones. We have recently demonstrated that 5 days of oral calcium supplementation significantly increases biliary calcium in the prairie dog (K. D. Lillemoe, T. H. Magnuson, G. E. Peoples, et al., Gastroenterology 94: A563, 1988). We hypothesized, therefore, that long-term oral calcium supplementation would promote pigment gallstone formation. Sixteen adult male prairie dogs were maintained on a standard nonlithogenic diet. Eight animals received calcium supplementation (2.5 x control levels) in their water, while the remaining eight animals served as controls. After 8 weeks, cholecystectomy was performed, and the common bile duct was cannulated. Bile was examined microscopically and analyzed for ionized calcium, bilirubin, glycoprotein, and biliary lipids. The cholesterol saturation index (CSI) was calculated. Pigment stones and calcium bilirubinate sludge were present in all animals receiving calcium supplementation. Only one control animal had evidence of pigment stones (P less than 0.001). Biochemical analysis of gallbladder bile demonstrated a significant increase in total bilirubin and bilirubin monoglucuronide (P less than 0.01) as well as bile glycoprotein content (P less than 0.05) after oral calcium supplementation. Gallbladder bile ionized calcium was also increased although not significantly. These data suggest that oral calcium supplementation promotes gallbladder sludge and pigment gallstone formation in the prairie dog. This observation raises concern that oral calcium supplementation, especially in the older female population, may enhance gallstone formation.

Animals↗
PubMed1989

Pancreatic lymphoma. Is surgery mandatory for diagnosis or treatment?

From 1982 to 1986, nine patients with non-Hodgkin's lymphoma primarily involving the pancreas were managed at the Johns Hopkins Medical Institutions. This group of nine patients represents 2.2% of patients with non-Hodgkin's lymphoma (nine of 402) and 4.9% of all patients presenting with pancreatic malignancies (nine of 182) at the Johns Hopkins Medical Institutions during this period. Computed tomography (CT) scan findings of a large pancreatic mass (6 cm) with extrapancreatic extension and significant retroperitoneal lymph node enlargement suggested lymphoma. Diagnosis was established by radiographically-guided needle biopsy in four patients, by laparotomy in four, and by peripheral lymph node biopsy in one. In five jaundiced patients, initial chemotherapy with the nonhepatotoxic agents cyclophosphamide and prednisone resulted in marked tumor regression, allowing for early resolution of jaundice and subsequent addition of more aggressive adriamycin containing combination chemotherapy. Overall, complete remission has occurred in six of nine patients, with a median survival of 24 months (range 4-69 months). It is concluded from this experience that the majority of patients with pancreatic lymphoma can be managed without surgery. Excellent control of symptoms, including jaundice, as well as long-term remission, can be obtained with chemotherapy alone. The only role for surgery in this setting may be to aid in establishing the diagnosis when percutaneous biopsy is nondiagnostic.

Aged↗
PubMed1989

The role of bacteria in gallbladder and common duct stone formation.

Debate continues as to the role that bacteria play in gallstone pathogenesis in Western countries. We therefore, examined gallbladder and common duct stones from 67 consecutive patients undergoing cholecystectomy and/or common bile duct exploration. Bile was cultured and stone cholesterol content was measured. Stones were examined by scanning electron microscopy (SEM) for bacteria. Individual calcium salts were classified by windowless energy-dispersive x-ray microanalysis. Gallbladder stones in 65 patients were identified as cholesterol in 46 (71%), black pigment in 17 (26%), and brown pigment in 2 patients (3%). Common bile duct stones from ten patients were cholesterol in 4, black pigment in 2, and brown pigment in 4 patients. The five patients with brown pigment stones were significantly (p less than 0.05) older, more likely to be men and to present with bile duct obstruction. Bile cultures were positive in 13% of patients with cholesterol stones, in 14% of those with black pigment stones, and in all of the patients with brown pigment stones (p less than 0.001). By SEM, bacteria were observed only within the calcium bilirubinate-protein matrix of brown pigment stones (p less than 0.001). In comparison to black pigment stones, brown stones were more likely to contain calcium palmitate (p less than 0.005) and cholesterol (p less than 0.001). We conclude that black and brown pigment stones have different pathogenic mechanisms and that bacterial infection is important only in the formation of brown pigment stones.

Adult↗
PubMed1989

Benign postoperative biliary strictures. Operate or dilate?

At The Johns Hopkins Hospital from 1979 through 1987, 42 patients had 45 procedures for benign postoperative biliary strictures. Three patients were managed with both surgery and balloon dilatation. Twenty-five patients underwent surgical repair with Roux-Y choledocho- or hepaticojejunostomy with postoperative transhepatic stenting for a mean of 13.8 +/- 1.3 months. Twenty patients had balloon dilatation a mean of 3.9 times and were stented transhepatically for a mean of 13.3 +/- 2.0 months. The two groups were similar with respect to multiple parameters that might have influenced outcome. Mean length of follow-up was 57 +/- 7 and 59 +/- 6 months for surgery and balloon dilatation, respectively. No patients died after any of the procedures. The same definition of a successful outcome was applied to both groups and was achieved in 88% of the surgical and in only 55% of the balloon dilatation patients (p less than 0.02). Significant hemobilia occurred more often with balloon dilatation (20% vs. 4%, p less than 0.02). The total hospital stay and cost of balloon dilatation was not significantly different from surgery. We conclude that surgical repair of benign postoperative strictures results in fewer problems that require further therapy. Nevertheless balloon dilatation is an alternative for patients who are at high risk or who are unwilling to undergo another operation.

Catheterization↗