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Biomedical subjects

R A Prinz

Publications and source records attributed to R A Prinz.

At least 55 records · Page 3Linked to original sources
PubMed1994

Plasmid labeling confirms bacterial translocation in pancreatitis.

To examine whether the gut is a source of infection in acute pancreatitis, bacterial translocation and alterations of intestinal microecology and morphology were studied in 16 dogs. Dogs were colonized with a strain of Escherichia coli (E. coli 6938K) bearing the plasmid pUC4K, which confers kanamycin resistance. In eight dogs (group I), pancreatitis was induced by sodium taurocholate/trypsin injection. Eight other dogs (group II) underwent laparotomy only. The pancreas, mesenteric lymph nodes, peritoneal fluid, liver, and spleen were harvested 7 days later for culturing and histologic analysis. Identification of E. coli 6938K was accomplished by plasmid DNA analysis. Group I dogs had severe pancreatitis and ischemic changes in small bowel mucosa. Group II dogs had no changes. Translocation to the pancreas occurred in five dogs and to mesenteric lymph nodes in six dogs with pancreatitis. No translocation occurred in group II dogs (p < 0.05). In addition to E. coli 6938K, other gram-negative kanamycin-resistant species were isolated, including E. coli (other than 6938K) and Enterobacter cloacae. Enteric origin of these strains was confirmed by antibiography and plasmid DNA analysis. No overgrowth of cecal gram-negative bacteria was found. This study suggests that the gut is a primary source of infection in pancreatitis and that ischemic damage of intestinal mucosa may promote bacterial translocation.

Acute Disease↗
PubMed1994

The clinical challenge of multiple pancreatic pseudocysts.

To evaluate the frequency of multiple pancreatic cysts, the likelihood of preoperative diagnosis, and therapeutic outcome, we retrospectively reviewed the records of 157 patients who underwent operation for pancreatic pseudocysts at 2 institutions between 1970 and 1992. Multiple pseudocysts were found in 29 (18.5%). The 8 women and 21 men ranged in age from 21 to 79 years. The etiology was alcohol abuse in 15 (52%), biliary tract disease in 6 (21%), alcohol abuse and biliary tract disease in 3 (10%), and a variety of other causes in the remaining 5 (17%). There was no difference in age, sex, race, etiology, or presenting signs and symptoms between patients with single pseudocysts and those with multiple cysts. Serum amylase levels were significantly higher in patients with multiple cysts compared to those with single cysts (P < 0.05). Computed tomography accurately demonstrated the extent of disease in 20 of 25 patients (80%), while 1 or more cysts were missed in 5 (20%). The mean number of cysts per patient was 2.7, with a range of 2 to 5. Average pseudocyst diameter was 7.8 cm, with a range from 3 to 20 cm. Multiple internal drainage procedures were performed in 19 patients, a combination of internal and external drainage in 6, external drainage in 1, and resection of multiple cysts in the tail in 2. There was no operative mortality. With a mean follow up of 38.5 months, only 1 recurrent pseudocyst has been found. There were six attempts at percutaneous drainage in six patients. Two of these patients were referred to our institution following failure of percutaneous drainage at other hospitals. Three other patients had residual symptomatic pseudocysts following percutaneous drainage at our hospitals and then underwent multiple internal drainage. The sixth patient refused operative drainage despite the persistence of residual symptomatic pseudocysts after attempted percutaneous drainage. The incidence of multiple pseudocysts (18.5%) is higher than previously reported. There is no difference in the clinical features of patients with single versus multiple pseudocysts. Patients with multiple cysts have higher serum amylase levels. Preoperative computed tomography underestimated the number of cysts in 20% of patients. Careful intraoperative exploration is still needed to avoid missing multiple pseudocysts. Internal drainage is the preferred therapy. A thorough search for multiple cysts at the initial operation should eliminate one potential cause for pseudocyst recurrence.

Adult↗
PubMed1994

Thoracoscopic excision of enlarged mediastinal parathyroid glands.

BACKGROUND: Most abnormal parathyroid glands can be removed through the neck, but those deep in the chest have required sternotomy or thoracotomy. To avoid the morbidity of these open procedures, ectopic parathyroid glands deep in the chest were removed with video-assisted thoracoscopy. METHODS: Two patients with persistent primary and two with persistent secondary hyperparathyroidism had technetium-thallium scintigraphy and computed tomography of the chest to localize their ectopic glands. Video-assisted thoracoscopy was used for operative removal of these glands in each patient. RESULTS: Parathyroid scans identified a mediastinal gland that was confirmed and localized precisely by the computed tomography scan. An enlarged ectopic gland weighing 1 to 2 gm was removed from each patient with normalization of serum calcium level. Glands were found by the main pulmonary artery, aortopulmonary window, ascending aorta, and aortic arch. One patient had recurrent disease 9 months later. CONCLUSIONS: Removal of parathyroid glands deep in the chest with video-assisted thoracoscopy is a safe and successful alternative to median sternotomy.

Adenoma↗
PubMed1994

A new method to obtain a tissue diagnosis of proximal bile duct tumors.

Klatskin tumors often pose a challenge for diagnosis and treatment. Most of these neoplasms are diagnosed clinically because of the difficulty in obtaining tissue that will provide histologic proof of the disease. When a non-operative course is sought, exhaustive attempts should be made to obtain a tissue diagnosis because of the potential for a false-positive clinical diagnosis. We describe a new way to obtain tissue for diagnosis by placing a laparoscopic choledochoscope through a percutaneous transhepatic cholangiogram track, thus allowing the tumor to be directly visualized and biopsied.

Bile Duct Neoplasms↗
PubMed1993

Surgical options in chronic pancreatitis.

Chronic pancreatitis is primarily a medical disease but surgery is indicated to treat complications, rule out malignancy, and ameliorate intractable pain. The ideal operation for chronic pancreatitis would relieve this pain while preserving exocrine and endocrine function. No one procedure achieves these goals in all patients so surgeons must tailor their operations to individual patient needs. In patients with a dilated pancreatic duct, complete ductal decompression with a lateral pancreaticojejunostomy is usually indicated. Pancreatic resection is useful in patients with localized disease, nondialated ducts, or in whom cancer cannot be ruled out. More rigorous documentation of the type and outcome of therapeutic interventions for chronic pancreatitis and the patient populations to whom they are applied is needed. Subjective measurements must be replaced by objective findings so that the true benefits of these procedures can be better assessed and compared.

Chronic Disease↗
PubMed1993

Somatostatin analog treatment of pancreatic fistulas.

In order to hasten healing of pancreatic fistulas, we have treated 11 men and one woman with octreotide, a long-lasting somatostatin analog. This agent was administered subcutaneously in doses of 0.05-0.20 mg, two to three times per day. Fistulas were secondary to pancreatic biopsy (1), pancreatic abscess drainage (2), operative injury (3), and blunt abdominal trauma (4). The two patients with fistulas secondary to pancreatic biopsy had outputs of 1000 mL/d. The patient with blunt trauma had pancreatic ascites, with outputs of 750 mL/d. The remainder had outputs of 100-250 mL/d for periods ranging from 1 wk to 11 mo. After octreotide administration, fistula output decreased from 360 +/- 347 mL/d to 110 +/- 131 mL/d on the first day of therapy (p < 0.05) and to 44 +/- 72 mL/d on the seventh day (p < 0.05). Seven patients eventually closed their fistulas. Failure to achieve fistula closure with octreotide was secondary to pancreatic duct stenosis (4); pseudocyst (1) or recurrent sepsis (4); and patient noncompliance (4). Somatostatin analogs are useful in the management of pancreatic fistulas. They significantly decrease (p < 0.05) the volume of fistula output, and they seem to aid fistula healing. Somatostatin analogs are safe even for outpatient management of pancreatic fistulas.

Adolescent↗
PubMed1993

Common bile duct obstruction by free floating tumor.

UNLABELLED: Tumors usually spread by local invasion or by vascular or lymphatic metastases. We report six patients in whom tumor cells were shed into the common bile duct with resulting obstruction. The three men and three women had jaundice and upper abdominal discomfort. Jaundice was intermittent in four patients. Preoperative total serum bilirubin ranged from 2.5 to 16.1 mg/dl; alkaline phosphatase ranged from 221 to 605 IU/1. Ultrasound showed a dilated gallbladder [GB] in five patients with dilated intrahepatic ducts in three and stones in only one. ERCP showed a single filling defect in two of three patients and multiple defects in one. PTC showed multiple defects in one patient. At operation a thick gelatinous tissue fragment or clot was seen in the common bile duct of each patient. Frozen section identified tumor tissue in all. The source was GB carcinoma [2], GB adenomyoma [1], hepatic metastases of colon cancer [2] and common bile duct cancer [1]. Treatment consisted of pancreaticoduodenectomy [2], including one for GB cancer, left hepatic lobectomy [1], choledochoduodenostomy [1], common duct exploration with T-tube insertion [1] and cholecystectomy [1]. One patient with metastatic colon cancer and another with gallbladder cancer died within one year of operation. The other four are alive from 2 to 4 years later. CONCLUSION: Benign or malignant tumors within the hepatobiliary tree can shed tissue into the common bile duct which can cause biliary obstruction. Any tissue fragment found in the common bile duct should be evaluated by frozen section. Recognition of this mode of tumor spread is needed for appropriate therapy of the underlying benign or malignant tumor.

Adenocarcinoma↗
PubMed1993

Surgical therapy in chronic pancreatitis.

Chronic pancreatitis should be treated medically until a surgically correctable complication develops. Incapacitating abdominal pain refractory to medical therapy is the most common indication for operation. Preoperative evaluation of chronic pancreatitis should include a dynamic computed tomography scan to evaluate the pancreas and pancreatic duct. If the pancreatic duct is not seen or is not dilated on computed tomography, an endoscopic retrograde cholangiopancreatogram should be performed. If the pancreatic duct is dilated more than 5 mm, a side-to-side pancreaticojejunostomy should be performed in symptomatic patients. If the pancreatic duct is not dilated and all other causes of pain have been ruled out, a pylorus-preserving Whipple resection or duodenum-preserving pancreatic head resection should be performed. Distal pancreatectomy is reserved for disease isolated to the tail. Total pancreatectomy is used only as a salvage procedure and, whenever possible, should be accompanied by autotransplantation of the residual gland or islet cells.

Chronic Disease↗
PubMed1993

Effect of failed computed tomography-guided and endoscopic drainage on pancreatic pseudocyst management.

BACKGROUND: Computed tomography and endoscopic drainage are used increasingly to treat pancreatic pseudocysts (PP). We reviewed our experience with PP to compare the outcomes of patients operated on initially (group 1) with those whose nonoperative treatment failed (computed tomography-guided or endoscopic drainage) before operation (group 2). METHODS: The records of 70 consecutive patients operated on for PP were reviewed. The 52 patients (74%) in group 1 and 18 (26%) in group 2 were compared in terms of clinical features, laboratory test results on examination and before operation, operative findings, morbidity, mortality, and recurrence rates. RESULTS: Before the initial drainage attempt, mean serum amylase level was higher in group 2 (542 +/- 25 vs 163 +/- 17 IU/L; p = 0.01). All other laboratory values were similar. Before operative drainage, group 2 patients had lower hemoglobin (10.7 +/- 0.5 vs 12.2 +/- 0.3 gm/dl; p < 0.05) and serum albumin level (2.7 +/- 0.2 vs 3.5 +/- 0.1 mg/dl; p < 0.01) than group 1. Morbidity was twice as frequent in group 2 (33% vs 14%). The time from initial attempt at drainage to PP resolution was longer in group 2 (104 +/- 36 vs 20 +/- 4 days; p = 0.01). However, the time from operation to resolution was similar in both groups (21 +/- 8 vs 20 +/- 4 days). CONCLUSIONS: Failed nonoperative drainage is associated with a protracted illness and carries a risk of increased morbidity after operative intervention.

Adult↗
PubMed1993

Early experience with laparoscopic approach for adrenalectomy.

BACKGROUND: Adrenalectomy performed by a posterior or transabdominal approach causes substantial postoperative pain. The purpose of this study was to evaluate laparoscopy as a potential approach for adrenalectomy. METHODS: We performed 25 consecutive laparoscopic adrenalectomies on 22 patients from April 1, 1992, to March 30, 1993. Laparoscopic surgery was performed by using a lateral decubitus flank approach with four 11 mm trocars. RESULTS: Twelve right and 13 left adrenal glands were removed in a mean time of 2.3 hours. Three patients underwent bilateral adrenalectomies in a mean time of 5.3 hours. The 15 women and 7 men range in age from 31 to 60 years (mean, 42 years). The adrenal gland diseases were nonfunctional adenoma (seven), pheochromocytoma (five), Cushing's disease (four), Cushing's adenoma (four), primary aldosteronism (two), dehydroepiandrostenedione sulfate hypersecretion (one), angiomyolipoma (one), and medullary cyst (one). Average tumor size was 4.1 cm (range, 1 to 15 cm). Laparoscopic adrenalectomy was successful in 96% of patients, with one patient requiring a laparotomy because of inadequate exposure. The median postoperative stay was 4 days (range, 2 to 19), with a mean of five narcotic injections. There were no deaths, and morbidity was minor. CONCLUSIONS: Laparoscopy can be used successfully for adrenalectomy. It produces less postoperative pain and rapid return to normal activity. It may be the preferred method for removing most adrenal gland lesions that require operation.

Adrenal Gland Diseases↗
PubMed1993

Fine-needle aspiration biopsy of adrenal masses in patients with extraadrenal malignancy.

BACKGROUND: Reports evaluating the efficacy of fine needle aspiration (FNA) of the adrenal gland have suggested a possible correlation between size of an adrenal mass and the presence of a primary or metastatic malignancy. These studies have focused on FNAs of all adrenal gland masses regardless of clinical history. This study investigates this relationship in a subpopulation of patients with a known history of primary extraadrenal malignancy. METHODS: All patients who have undergone computed tomographic-guided FNA biopsy of an adrenal mass at Loyola University Medical Center and Hines Veterans Administration Hospital, from 1985 to 1991, were reviewed. RESULTS: If size was assumed to be an independent predictor for presence of metastases, the highest efficiency was obtained with a cutoff value of 3 cm. This value divided the group into 15 (42%) "low-risk" (< or = 3 cm) and 21 (58%) "high-risk" (> 3 cm) subjects. In the "low-risk" group, 87% of the masses (13 of 15) were benign and 13% (2 of 15) were malignant. Within the "high-risk" group, more than 95% of the masses (20 of 21) were malignant, with a single (5%) benign case (p < 0.05). CONCLUSIONS: There is a significant correlation between the size of an adrenal nodule and the presence of metastases in patients with a known primary extraadrenal malignancy. Nodules greater than 3 cm have a very high probability of involvement by metastatic tumor. Nodules 3 cm or smaller are usually benign, but metastatic tumor can still be found in up to 13%. FNA biopsy is useful in evaluating adrenal masses in this setting.

Adrenal Gland Diseases↗
PubMed1993

Clinical features of duodenal somatostatinomas.

BACKGROUND: Duodenal somatostatinomas are rare tumors that are often asymptomatic or present with local symptoms rather than with evidence of excess somatostatin production. To characterize the clinical presentation and management of these neoplasms we reviewed the course of four patients. METHODS: The records of three men and one woman with duodenal somatostatinomas, who were treated between 1988 and 1992, are reviewed. RESULTS: Three of the patients presented with vague gastrointestinal complaints, and one was free of symptoms. No patient had symptoms of somatostatinoma syndrome, nor did any have associated neurofibromatosis. Three patients were diagnosed after biopsy of a submucosal mass during upper endoscopy. Three patients with tumors that measured less than 2 x 2 cm underwent local resection. One patient with a large tumor and liver metastases underwent a Whipple's operation and resection of the liver lesions. Immunohistochemically all tumors predominantly contained somatostatin, although each had traces of other neuropeptides. All tumors contained psammoma bodies. Follow-up periods ranged from 1 to 4 years. CONCLUSIONS: Duodenal somatostatinomas often appear with only local symptoms or are completely asymptomatic. Small tumors may be locally excised. Intraarterial methylene blue injection may help localize very small tumors during operation. Larger tumors, including those with localized metastases, should also be resected when possible.

Aged↗
PubMed1993

Laparoscopic cholecystectomy bile duct injuries: more than meets the eye.

Laparoscopic cholecystectomy (LC) has rapidly become standard treatment of symptomatic cholelithiasis. Its advantages are well known, while its risks have not been well defined. The most common major complication of LC is bile duct injury. Over the past year, we have treated six patients for this problem. Injuries included: one partial laceration of the common bile duct; one partial laceration of the common hepatic duct; three complete common hepatic duct transections at the bifurcation, and one clip obstruction of the right hepatic duct. Intraoperative cholangiography was performed in two of six patients. Injury was recognized in these two cases, which were converted to celiotomy for immediate repair. One was repaired primarily; the other required a hepaticojejunostomy. Injuries were not identified at LC in four. Three of the four patients required biliary-enteric reconstruction procedures. With a mean follow-up period of 13 months, four of six patients remain symptomatic. LC does carry a real risk of bile duct injury. Routine intraoperative cholangiography may decrease this risk or at least allow early recognition and repair when it has occurred. Conversion to an open procedure is not a complication of LC but rather a sign of good surgical judgement. Patients not following the routine postoperative course must be evaluated for a possible bile duct injury to prevent the morbidity of delayed diagnosis.

Adolescent↗
PubMed1993

Localization of islet cell tumors of the pancreas: a review of current techniques.

Operative exploration with attempted curative resection should be attempted on virtually all patients with islet cell tumors of the pancreas who do not have metastatic disease evident on preoperative studies. Because of the small size and variable location of many of these neoplasms, localization studies play an important role in ensuring appropriate and successful surgical therapy. A review of currently available preoperative and intraoperative aids for tumor localization is presented. A new technique of selective intraarterial injection of methylene blue is described along with a report of our preliminary results. Further evaluation and use of this technique and other newly developed technologies are warranted to lower the commonly reported 10% to 30% negative exploration rate for these sometimes elusive tumors.

Adenoma, Islet Cell↗
PubMed1992

Adenocarcinoma of the pancreas coexisting with pancreatic abscess.

Of 20 patients treated for pancreatic abscess during the years 1984-1991, two patients were found to have adenocarcinoma of the pancreas associated with their pancreatic abscesses. In one patient an adenocarcinoma of the proximal pancreas caused ductal obstruction, which may have been the primary cause of an abscess distal to the tumor. In the second patient, metastatic adenocarcinoma of the pancreas and a concurrent pancreatic abscess were found when the patient's abdomen was explored for complications related to gallstone pancreatitis. In both patients, the tumor was unresectable at presentation. A detailed review of these cases is presented as well as a review of the related literature.

Abscess↗
PubMed1992

Selective intra-arterial methylene blue injection: a novel method of localizing gastrinoma.

A 40-year-old woman had persistent Zollinger-Ellison syndrome despite excision of a 4-cm duodenal gastrinoma. Localizing studies including ultrasonography, computed tomography, magnetic resonance imaging, duodenal endoscopy, endoscopic ultrasonography, and intraoperative endoscopic transillumination of the duodenum failed to detect a tumor. Selective intra-arterial methylene blue injection was used to identify a 6-mm gastrinoma in the duodenum, which was locally excised. Postoperatively, the patient had a negative secretin provocative test result. This novel method uses selective arterial secretin injection with hepatic venous gastrin sampling to identify the vessel feeding the gastrinoma. An angiographic catheter is then positioned in this artery. At laparotomy, methylene blue is injected through this catheter to selectively stain the gastrinoma, facilitating its identification. Selective intra-arterial methylene blue injection can enhance intraoperative detection of small gastrinomas and may improve the rate of curative resection in the Zollinger-Ellison syndrome. Further evaluation of this novel localizing technique is warranted.

Adult↗
PubMed1992

Effect of somatostatin analogue and cholecystokinin receptor antagonist on bile-induced acute canine pancreatitis.

To determine whether a synthetic somatostatin analogue, octreotide, and a cholecystokinin receptor antagonist, L-364,718, may be beneficial in acute pancreatitis, 33 dogs were assigned to four groups. Each dog underwent laparotomy with injection of autologous bile into the dorsal pancreatic duct. Thirty minutes after the induction of pancreatitis, Group 1 received a subcutaneous injection of octreotide (200 micrograms/kg), Group 2 received an equal volume of the octreotide carrier, Group 3 received an hourly intravenous bolus of L-364,718 (60 micrograms/kg), and Group 4 received an equal volume of the L-364,718 carrier. Hemodynamic profiles, arterial blood gases, plasma glucose, and serum amylase were obtained before laparotomy, at bile injection, and at hourly intervals. The pancreas was removed after 8 hours for gross evaluation, measurement of water content, and histologic examination. A significant decrease in cardiac index and a significant increase in serum amylase and pancreatic edema occurred in all four groups 8 hours after the induction of pancreatitis (P less than 0.05), but there was no statistical difference between any group. Likewise, there was no difference in gross or histologic changes in the pancreas of any group. The somatostatin analogue, octreotide, and the cholecystokinin receptor antagonist, L-364,718, did not ameliorate the effects of severe, bile-induced pancreatitis in dogs.

Acute Disease↗