Biomedical subjects

H A Pitt

Publications and source records attributed to H A Pitt.

At least 163 records · Page 9Linked to original sources

PubMed1986

Pancreatoduodenectomy with pylorus preservation for adenocarcinoma of the head of the pancreas.

For many years, the classical Whipple procedure has been the standard operative treatment for resectable periampullary cancer. Recently, the pylorus preservation operation has also been applied to periampullary tumours. This newer procedure has potential advantages in terms of ease of performance and postoperative physiology, but has yet to be proved as an adequate cancer operation. We, therefore, undertook the present retrospective analysis to compare the outcome following the pylorus preservation operation (n = 13) with that of the classical Whipple resection (n = 13) in 26 patients with histologically proved adenocarcinoma of the head of the pancreas. The two groups of patients were comparable for age, sex, pre-operative laboratory data, and resected margins free from tumour. More patients undergoing the classical Whipple resection had Stage I disease (10 versus 4, P less than 0.05). However, this difference would not be significant if the two patients in the pylorus preservation group with carcinomas in situ were considered to have stage I disease. Mean tumour diameter in the pylorus preservation patient group (3.2 +/- 0.6 cm) was smaller (P less than 0.05) than in the classical Whipple group (4.1 +/- 1.0 cm) but more patients in the pylorus preservation group also had metastases to the regional lymph nodes (54 versus 23 per cent). Overall operative morbidity (31 per cent) and mortality (4 per cent) was acceptable and did not differ between the two groups. Five year actuarial survival for pylorus preservation (25 per cent) was comparable to that observed for the Whipple procedure in this and other series.

Adenocarcinoma↗

PubMed1986

Decreased morbidity and mortality after pancreatoduodenectomy.

In two 5 year periods (1975 to 1979 and 1980 to 1984), 96 patients underwent pancreatoduodenal resection, which included 74 partial pancreatic resections and 22 total pancreatectomies. Thirty-seven of these patients had resections with preservation of the pylorus. Substantial reductions in perioperative mortality (2 percent versus 10 percent) and morbidity (26 percent versus 49 percent) (p less than 0.05) were achieved in the latter period. Pylorus preservation, with a mortality and morbidity of 3 percent and 27 percent, respectively, did not increase operative risk or compromise long-term survival in patients with malignant disease. In comparison, relatively high mortality and morbidity rates (14 percent and 59 percent) accompanied total pancreatectomy without improved long-term survival. Five year actuarial survival for nonpancreatic periampullary adenocarcinomas was 58 percent. Thus, we recommend pancreatoduodenectomy with preservation of the pylorus for resection of periampullary tumors. These patients, whose only possibility for cure is a major pancreatic resection, should not be denied this opportunity on the basis of reports from a previous era.

Actuarial Analysis↗

PubMed1986

Management of hepatic echinococcosis in Southern California.

In the United States, hydatid disease of the liver is being seen with increasing frequency in persons who have immigrated from endemic areas. At the University of California, Los Angeles Medical Center, 24 patients with 46 echinococcal cysts were managed over a 26 year period. Seven patients (29 percent) had cyst rupture: into the lungs in three patients, the biliary tree in two, and the peritoneum and duodenum in one patient each. In recent years, serologic tests, computerized axial tomography, and endoscopic retrograde cholangiopancreatography have greatly aided the diagnosis and management of these patients. Four patients were treated nonoperatively, and 20 patients (with a total of 41 cysts) underwent operation. Cyst management included partial cystectomy in 19 patients, complete cystectomy in 18 patients, left hepatic lobectomy in 2 patients, and marsupialization and removal of hepatic debris from the common duct in 1 patient each. Primary cyst closure, omental packing, external drainage, or cystojejunostomy was individualized on the basis of cyst size, location, secondary infection or rupture, and communication with the biliary tree. Morbidity, including two temporary external biliary fistulas, occurred in eight patients (40 percent) but could not be related to cyst management or preoperative rupture. No deaths occurred in this series.

Adolescent↗

PubMed1986

Carbohydrate diet-induced calcium bilirubinate sludge and pigment gallstones in the prairie dog.

Epidemiologic studies suggest that consumption of diets rich in carbohydrates may, in part, be responsible for the increasing incidence of pigment gallstone disease. The mechanism by which these dietary components lead to pigment stone formation remains obscure. Furthermore, investigative efforts in this area have been hampered by the lack of a suitable animal model. The present study was undertaken to study the role of complex carbohydrates in pigment gallstone formation in the prairie dog. Two groups of eight animals each were maintained on either a control, nonlithogenic chow, or a high carbohydrate (35% sucrose, 32% rich starch) diet for 2 months. Neither crystals nor gallstones were observed in any of the control animals. All of the carbohydrate fed animals (P less than 0.005 vs control) had calcium bilirubinate crystals and sludge, while microscopic, black stones were present in six of these eight animals (P less than 0.05 vs control). Although hepatic bile bilirubin was unchanged in the carbohydrate-fed group, these animals had a significant increase in hepatic bile calcium (P less than 0.005) and phospholipids (P less than 0.005) when compared to controls. Carbohydrate-fed animals also had a significant increase in gallbladder bile concentrations of phospholipids (P less than 0.001), calcium (P less than 0.001), unconjugated (P less than 0.005), conjugated (P less than 0.005), and total bilirubin (P less than 0.001) as compared to controls. These data indicate that in the prairie dog, carbohydrate feeding results in increased biliary concentrations of phospholipids, calcium and bilirubin, and formation of calcium bilirubinate crystals, sludge and microscopic gallstones.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

PubMed1986

The effect of parenteral nutrition on biliary calcium and bilirubin.

Recent studies have suggested that patients maintained on prolonged total parenteral nutrition (TPN) are at increased risk for gallstone formation. Animal and human data suggest that TPN causes calcium bilirubinate sludge and pigment gallstones. However, the effect of TPN on bile bilirubin and calcium concentrations has not previously been investigated. We, therefore, tested the hypothesis that TPN alters biliary bilirubin and calcium. Eight adult male prairie dogs received TPN (dextrose 15%, FreAmine III 4.25%, Intralipid 10%, insulin 25 U, electrolytes, and vitamins) at a rate of 80 cc/kg/day for 10 days. Eight additional animals maintained on a trace cholesterol diet served as controls. Gallbladder and hepatic bile samples were assayed for bilirubin and calcium. Cholesterol saturation index (CSI) and Rsa, a measure of gallbladder stasis, were also calculated. Calcium bilirubinate crystals were seen in gallbladder bile or wall scrapings of 7 of 8 TPN animals but in none of the controls (P less than 0.001). Animals that received TPN had bilirubin levels that were significantly higher in gallbladder bile (24.8 +/- 7.0 vs 5.1 +/- 0.9, P less than 0.05). Similarly, TPN animals had calcium levels that were significantly higher in gallbladder (30.0 +/- 3.6 vs 13.9 +/- 2.1, P less than 0.005) as well as hepatic (10.5 +/- 0.6 vs 7.4 +/- 0.6, P less than 0.005) bile. The Rsa values were also significantly lower (P less than 0.01) in TPN animals (0.57 +/- 0.07 vs 1.06 +/- 0.14). CSI, serum bilirubin, serum calcium, hematocrit, and reticulocyte counts did not differ between groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

PubMed1986

Enhanced gallbladder absorption during gallstone formation: the roles of cholesterol saturated bile and gallbladder stasis.

Cholesterol saturated bile and gallbladder stasis are important factors in the pathogenesis of cholesterol gallstones. The degree to which either or both of these factors affect gallbladder transport of fluid remains obscure. The authors tested the hypothesis that both cholesterol saturated bile and gallbladder stasis, and not stasis alone, promotes gallbladder fluid absorption. Prairie dogs were maintained for 2 weeks on either a control chow, total parenteral nutrition (TPN), or a 1.2% cholesterol enriched chow. The bile acid pool was labeled with 14C-cholic acid and indexes for cholesterol saturation (CSI) and gallbladder stasis (Rsa) were determined. Fluid transport was indirectly measured by calculating the ratio of gallbladder to hepatic bile concentrations of individual and total biliary lipids. Despite evidence of stasis in prairie dogs maintained on TPN, bile was unsaturated, and gallbladder absorption was not appreciably changed. In contrast, cholesterol-fed animals had cholesterol supersaturated bile, gallbladder stasis, and altered gallbladder absorption, as manifested by a significant change in the ratio of gallbladder to hepatic bile concentrations of individual and total biliary lipids. These data suggest that both cholesterol saturated bile and gallbladder stasis, and not stasis alone, are essential in promoting the enhanced gallbladder absorption, which has previously been observed during early cholesterol gallstone formation.

Absorption↗

PubMed1986

Differentiation of pyogenic from amebic hepatic abscesses.

Recent immigration trends have resulted in an increased prevalence of amebic hepatic abscesses in southern states and in many northern American cities. Because amebic hepatic abscesses generally do not require drainage, differentiation from pyogenic hepatic abscesses is important. We, therefore, reviewed the records of patients admitted to the UCLA Medical Center from 1968 through 1983 to compare the clinical manifestations and to access the results of treatment of pyogenic and amebic hepatic abscesses. During this 15 year period, 82 patients (42 pyogenic and 40 amebic) with hepatic abscesses were admitted. Factors which distinguished patients with pyogenic abscesses included: age greater than 50 years; jaundice; pruritus; sepsis and shock; a palpable mass; elevated bilirubin level; elevated alkaline phosphatase level, and abnormal abdominal roentgenograms. Patients with amebic abscesses of the liver were more likely to have Mexican ancestry, recently traveled to an endemic area, abdominal pain, diarrhea, abdominal tenderness, hepatomegaly and positive amebic serology. Hepatic scans and ultrasonography were excellent methods of detecting the presence of but not the type of hepatic abscess. Over-all, the mortality was 40 per cent for patients with pyogenic abscesses whereas all 40 of the patients with an amebic abscess survived. However, operative mortality was only 4.5 per cent for the 22 patients with pyogenic abscess who were managed with systemic antibiotics and surgical drainage. We conclude that many clinical and laboratory parameters can aid in the differentiation and, as a result, management of patients with pyogenic and amebic hepatic abscesses.

Adolescent↗

PubMed1985

Chronic intestinal pseudo-obstruction. Management with total parenteral nutrition and a venting enterostomy.

A variety of remedies have been suggested for patients with chronic intestinal pseudo-obstruction. However, none of these treatments have been particularly effective, and many of these patients have died of malnutrition. Therefore, in an effort to maintain nutrition and avoid repetitive nasogastric intubation, 22 patients (12 adults and ten children) with chronic intestinal pseudo-obstruction were managed with long-term total parenteral nutrition (TPN), and 20 also received a "venting" enterostomy. Only two patients had to undergo revision of their gastrostomies. Prior to referral, these 22 patients required 56 admissions for obstruction (1.2 admissions per patient-year). Since the initiation of TPN and placement of a venting enterostomy, these 22 patients required only 17 hospitalizations for obstruction in a total of 80 patient years (0.2 admissions per patient-year). We conclude that patients with chronic intestinal pseudo-obstruction who receive TPN at home and have a venting enterostomy can be safely managed for prolonged periods and require fewer hospitalizations for obstruction.

Adolescent↗

PubMed1985

Effect of pancreatic polypeptide on gallbladder filling.

Recent studies suggest that pancreatic polypeptide (PP) alters gallbladder pressure and reduces delivery of bile to the duodenum. Whether this peptide influences gallbladder emptying and/or filling is not clear. Using the prairie dog model, we tested the hypothesis that exogenous PP induces gallbladder filling. Animals maintained on control diets underwent laparotomy with placement of catheters into the gallbladder and common bile duct. The gallbladder was perfused with [14C]polyethtyleneglycol ([14C]PEG)-labeled lactated Ringer's solution (LR) at 0.1 ml/min. Effluent from the common bile duct was collected at 5-min intervals during 30-min intravenous infusions of LR, LR + 2% serum albumin, and LR + 2% serum albumin + bovine PP (10 and 50 ng/kg/min). Gallbladder pressure was continuously recorded. Total and incremental fillings were calculated based on volume and [14C]PEG concentration changes. Infusion of PP, 50 ng/kg/min, induced significant gallbladder filling. The filling response was progressive and peaked during the final 10 min of peptide infusion. These findings coupled with the observation that serum PP levels are increased for up to 6 hr postprandially suggest that PP may play an important role in the regulation of interdigestive gallbladder filling.

Animals↗

PubMed1985

Experience with sphincteroplasty and sphincterotomy in pancreatobiliary surgery.

Review of a 26-year experience with transduodenal sphincteroplasty and sphincterotomy was undertaken (1) to analyze critically the indications for and results of these procedures and (2) to determine which preoperative factors correlate with a good or poor outcome. Of 109 patients, 78 underwent sphincteroplasty, whereas 31 had a transduodenal sphincterotomy. Surgical indications included: group 1, 53 patients with common duct stones; group 2, 28 patients with dyskinesia or stenosis of the sphincter of Oddi (without choledocholithiasis or recurrent pancreatitis); and group 3, 28 patients with recurrent pancreatitis. Three elderly group 1 patients who presented with cholangitis died after surgery (a hospital mortality of 2.7%). Seventy-nine of the 103 patients (77%) in whom follow-up was obtained achieved an excellent or good result. Results were almost identical with sphincteroplasty and sphincterotomy. Abnormal preoperative liver function tests were the only predictors of a good postoperative outcome (p less than 0.05). Group 3 patients (good results in 63%) had significantly poorer (p less than 0.05) outcome than group 1 and 2 patients. Results were worst in group 3 patients who had undergone previous abdominal or pelvic surgery (p less than 0.025) and in group 2 patients who were narcotic users (p less than 0.025). The authors conclude that transduodenal sphincteroplasty or sphincterotomy can be performed relatively safely, but caution that careful selection of patients is important when the indication for surgery is either ampullary stenosis or recurrent pancreatitis.

Adolescent↗

PubMed1985

Does preoperative percutaneous biliary drainage reduce operative risk or increase hospital cost?

Despite recent advances in perioperative support care, surgery for obstructive jaundice is still associated with significant morbidity and mortality. For this reason, preoperative percutaneous transhepatic drainage (PTD) has been recommended for these patients. This method of management, however, has only been supported by retrospective and nonrandomized studies. Therefore, a prospective, randomized study was performed to determine the effect of preoperative PTD on operative mortality, morbidity, hospital stay, and hospital cost. Thirty-day mortality was 8.1% among 37 patients undergoing preoperative PTD, compared to 5.3% for 38 patients who went to surgery without preoperative drainage. Overall morbidity was also slightly, but not significantly, higher in patients who underwent preoperative PTD, (57% versus 53%). However, total hospital stay was significantly longer (p less than 0.005) in the PTD group (31.4 days versus 23.1 days). The cost of this excess hospitalization and the PTD procedure at our university medical center was over +8000 per patient. The authors conclude that preoperative PTD does not reduce operative risk but does increase hospital cost and, therefore, should not be performed routinely.

Adenocarcinoma↗

PubMed1985

Cholecystokinin prophylaxis of parenteral nutrition-induced gallbladder disease.

Recent studies indicate that long-term total parenteral nutrition (TPN) induces gallstone formation and acalculous cholecystitis in humans. Cholecystectomy is hazardous for these patients because they frequently have multiple medical problems and have undergone numerous abdominal operations. The present study was designed to develop a method to prevent TPN-induced gallbladder disease. The authors tested the hypothesis that a single daily intravenous infusion of cholecystokinin-octapeptide (CCK-OP) will prevent TPN-induced gallbladder stasis. Eleven prairie dogs received TPN for 10 days. Six of these animals were given a daily infusion of CCK-OP. Control animals were fed ad lib. Each animal's bile salt pool was labeled with intravenous 3H-cholic acid 16 hours prior to acute terminal experiments. The ratio of gallbladder to hepatic bile 3H-cholic acid specific activity (Rsa) provides an index of gallbladder stasis. A Rsa of less than 1.0 indicates gallbladder stasis. TPN animals had a Rsa of 0.54 +/- 0.13 (p less than 0.01 vs. controls), indicating stasis of bile in the gallbladder. Daily CCK-OP infusions resulted in a Rsa of 0.92 +/- 0.10 (p less than 0.05 vs. TPN without CCK-OP), indicating that TPN-induced gallbladder stasis is prevented by daily CCK-OP. Control animals had a Rsa of 1.03 +/- 0.06. The cholesterol saturation indices of gallbladder and hepatic bile were not increased by TPN or CCK-OP. These data indicate that 1) TPN induces gallbladder stasis but does not increase bile lithogenic index; and 2) daily injections of CCK-OP prevent TPN-induced gallbladder stasis.

Animals↗

PubMed1985

Anatomy of the choledochopancreatic duct junction in primary sclerosing cholangitis.

Primary sclerosing cholangitis (PSC) is a rare disease for which the etiology is unknown. Because abnormalities of the choledochopancreatic duct junction (CDPDJ) have been implicated in the pathogenesis of other rare biliary problems such as choledochal cysts and biliary atresia, we reviewed the cholangiographic anatomy of the CDPDJ in our patients with PSC. From 1955 through July 1983, 46 patients with PSC were seen at the University of California at Los Angeles Medical Center. In 20 of these 46 patients anatomy of the CDPDJ could be evaluated by review of endoscopic retrograde cholangiopancreatography (11 patients) or by reflux into the pancreatic duct during transhepatic, operative, or postoperative tube cholangiography (nine patients). Roentgenograms were evaluated for the length of common channel of the biliary and pancreatic ducts and the degree of reflux into and anatomic abnormalities of the pancreatic duct. All bile ducts were abnormal, and pancreatic duct reflux occurred in 14 of 42 patients (33%) who underwent transhepatic or tube cholangiography. An abnormally long (greater than 15 mm) common channel was present in two of 20 patients (10%), pancreatic duct reflux of more than 100 mm occurred in six of 14 patients (43%), and pancreatic duct abnormalities were seen in nine of 18 patients (50%). These data suggest that in patients with PSC abnormal pancreatic duct reflux and anatomy are common but variations in the anatomy of the CDPDJ are rare. However, altered function of the CDPDJ may contribute to excessive reflux into and anatomic changes of the pancreatic ducts and the moderate incidence of pancreatitis observed in patients with PSC.

Adult↗

PubMed1984

Parenteral nutrition-induced gallbladder disease: a reason for early cholecystectomy.

Patients who receive long-term parenteral nutrition have an increased incidence of both calculous and acalculous cholecystitis. In an attempt to establish guidelines for the clinical management of patients with TPN-induced gallbladder disease, we have reviewed the records of 35 patients who have undergone cholecystectomy for this problem since 1976 at the UCLA Medical Center. The mean age of the 23 adult and 12 children who had cholecystectomy was 29.1 years. Forty percent of these patients required emergency cholecystectomy. The overall operative morbidity was 54 percent, and the hospital mortality was 11 percent. Significant factors contributing to this high rate of complications included a delay in diagnosis, especially in the young children, and increased operative difficulty due to extensive adhesions and intraoperative hemorrhage. Our analysis suggests that patients receiving long-term TPN should have a program of ultrasound surveillance for gallstone formation, elective cholecystectomy when stones first appear, and consideration of cholecystectomy at the time of laparotomy performed for other reasons. Whether TPN-induced gallstones can be prevented through daily stimulated gallbladder emptying awaits the results of future studies.

Adult↗

PubMed1984

The cholecysto-sphincter of Oddi reflex.

Multiple factors including hormonal and neural influences as well as intravascular volume, body temperature, and pharmacologic agents have been shown to influence sphincter of Oddi function. Recent studies have also suggested that mechanical or electrical stimulation of the gallbladder and the degree of gallbladder filling may affect the frequency and amplitude of sphincter of Oddi phasic contractions. However, the effect of gallbladder filling on sphincter of Oddi phasic wave direction has not previously been studied. In acute terminal experiments, eight adult male prairie dogs underwent cannulation of the gallbladder with a pressure-monitored perfusion catheter. The common bile duct was cannulated proximally with a drainage catheter and distally with a triple-lumen, side-hole, closed-tipped catheter. The distal port of this catheter was positioned in the sphincter of Oddi (SO) while the proximal port was in the distal common bile duct (CBD). Distal CBD and SO phasic wave activity was recorded first with the gallbladder perfused with lactated Ringer's solution at 0.1 ml/min (mean intragallbladder pressure 8.1 +/- 0.3 mm Hg) and then with the gallbladder (GB) empty. Sphincter of Oddi phasic wave frequency was 6.7 +/- 0.9/min with the GB full and 5.4 +/- 0.6/min with the GB empty (P less than 0.02). Phasic wave amplitude was also greater with the GB full versus empty in both the distal CBD (6.4 +/- 0.6 vs 4.3 +/- 0.5 mm Hg, P less than 0.05) and the SO (9.5 +/- 1.5 vs 6.4 +/- 0.8, P = 0.075). Baseline pressures and the direction of phasic waves were unaffected by the degree of gallbladder filling.(ABSTRACT TRUNCATED AT 250 WORDS)

Ampulla of Vater↗

PubMed1984

Sclerosing cholangitis and histiocytosis X.

Three patients with biopsy proven histiocytosis X who developed a clinical and pathological picture compatible with sclerosing cholangitis are reported. In one patient, operative biopsy of the common bile duct revealed histiocytosis X in the granulomatous/xanthomatous phase. At necropsy, however, only fibrosis of the biliary tree was seen, a picture consistent with sclerosing cholangitis. Fibrotic obstruction of the biliary tree led to death from liver failure in all three patients. The aetiology of primary sclerosing cholangitis is unknown and may be multifactorial. Perhaps involvement of the biliary tree by histiocytosis X is one cause.

Adolescent↗

PubMed1984

Ileal resection-induced gallstones: altered bilirubin or cholesterol metabolism?

Ileal resection has been shown to increase the risk of cholelithiasis. Earlier studies in humans suggested that ileal resection increases the cholesterol saturation index. Recent data from patients on long-term parenteral nutrition and from animals, however, have suggested that ileal resection predisposes to pigment gallstone formation. We therefore tested the hypothesis that ileal resection alters bile calcium and bilirubin metabolism without affecting the cholesterol saturation index. Adult male prairie dogs underwent either sham laparotomy (eight prairie dogs) or ileal resection (16 prairie dogs). All animals were fed a trace cholesterol (nonlithogenic) diet before and for 4 weeks after operation. Pigment gallstones were present in 44% of the ileal-resected animals and in none of the sham animals (p less than 0.05). Calcium bilirubinate crystals were present in 94% of the ileal-resected animals and in none of the sham animals (p less than 0.01). Gallbladder bile calcium (25.6 +/- 2.4 versus 17.2 +/- 1.1 mg/dl; p less than 0.05) and total bilirubin (29.3 +/- 4.0 versus 9.4 +/- 1.8 mg/dl; p less than 0.01) concentrations were significantly greater in ileal-resected animals. The cholesterol saturation index of gallbladder bile, however, was no different in ileal-resected (0.53 +/- 0.04) and in sham-operated animals (0.50 +/- 0.04). Although initial studies suggested that the cholesterol saturation index of hepatic bile was increased after ileal resection, a second set of experiments demonstrated that this phenomenon resulted from washout of bile salts that were already in extremely low concentrations in hepatic bile. We conclude that alterations in bilirubin, but not cholesterol, metabolism result in pigment gallstone formation after ileal resection.

Animals↗

PubMed1983

Percutaneous transhepatic drainage. Risks and benefits.

We evaluated the risks and benefits of percutaneous transhepatic biliary drainage (PTD) in 44 patients. Patients were divided into two groups, palliative and preoperative, each of which had 22 patients. Major complications included bacteremia, hemobilia, and liver abscess and occurred in ten patients (23%). A liver abscess along the catheter tract may have contributed to the death of one patient with an advanced malignant neoplasm. Major complications were more likely to develop in palliative-group patients (36% v 9%) and those patients were more likely to die within 30 days of the procedure (27% v 0%). Four (57%) of seven palliative-group patients and none of six preoperative-group patients with pre-PTD bilirubin levels higher than 20 mg/dL died within 30 days after PTD. Liver function test results improved within seven days in approximately 85% of the patients. Twenty-one patients (95%) in the preoperative group survived surgery. We concluded that the risk of PTD may outweigh the benefit in the subset of patients with advanced malignant neoplasms and a bilirubin level higher than 20 mg/dL. Even then, however, PTD may be justified if pruritus is incapacitating. Pending results of further randomized trials, we have continued performing PTD preoperatively in patients whose bilirubin levels exceed 10 mg/dL.

Adolescent↗