Revision of anastomotic stenosis after pancreatic head resection for chronic pancreatitis: is it futile?

BACKGROUND

Because survival after pancreaticoduodenectomy for cancer is limited, it is difficult to assess longterm pancreaticojejunal anastomotic patency. However, in patients with benign disease, pancreaticojejunal anastomotic stenosis may become problematic. What happens when pancreaticojejunal anastomosis revision is undertaken?

METHODS

Patients undergoing pancreatic anastomotic revision after pancreatic head resection for benign disease between 1997 and 2007 at the Medical University of South Carolina were identified. A retrospective chart review and analysis were undertaken with the approval of the Institutional Review Board for the Evaluation of Human Subjects. Longterm follow-up was obtained by patient survey at a clinic visit or by telephone.

RESULTS

During the study period, 237 patients underwent pancreatic head resection. Of these, 27 patients (17 women; median age 42 years) underwent revision of pancreaticojejunal anastomosis. Six patients (22%) had a pancreatic leak or abscess at the time of the index pancreatic head resection. The indication for revision of anastomosis was intractable pain. All patients underwent preoperative magnetic resonance cholangiopancreatography (MRCP), which indicated anastomotic stricture in 18 patients (63%). Nine other patients underwent exploration based on clinical suspicion caused by recurrent pancreatitis and stenosis was confirmed at the time of surgery. Six patients (22%) had perioperative complications after revision. The median length of stay was 12 days. There were no perioperative deaths; however, late mortality occurred in four patients (15%). Six of 23 survivors (26%) at the time of follow-up (median 56 months) reported longterm pain relief.

CONCLUSIONS

Stricture of the pancreaticojejunal anastomosis after pancreatic head resection presents with recurrent pancreatitis and pancreatic pain. MRCP has good specificity in the diagnosis of anastomotic obstruction, but lacks sensitivity. Pancreaticojejunal revision is safe, but rarely effective, as a means of pain relief in patients with the pain syndrome associated with chronic pancreatitis.

Management of Common Bile Duct Injury during Partial Gastrectomy

Injury to the common bile duct (CBD) during upper gastrointestinal surgery for peptic ulcer disease is a serious complication with an underestimated prevalence in light of the few cases reported in the surgical literature. Three cases of CBD injury were referred to a multidisciplinary specialized gastrointestinal unit for management over a 4-year period. Anomalous anatomy, adhesions, and potential duodenal shortening secondary to contracture all predispose the biliary ducts to intraoperative injury. The axial nature of the blood supply to the extrahepatic ducts and the tendency of bile itself to cause rapid collagen turnover and fibrosis, combined with the inflammation and subsequent fibrosis to the surrounding tissues caused by bile leakage, give the bile ducts a high propensity for stricture formation. Frequently presenting symptoms of CBD injury immediately after surgery include jaundice, elevated bilirubin values, elevated t-tube drainage, and symptoms of sepsis. The most common complaints noted in patients who present in a delayed manner are symptoms of cholangitis. Even when injuries are rapidly identified and corrected, the potential for lasting negative impact on quality of life is great in many cases. When CBD injury occurs, the pancreatic duodenal union can be concomitantly disrupted.

Management of common bile duct injury during partial gastrectomy

Injury to the common bile duct (CBD) during upper gastrointestinal surgery for peptic ulcer disease is a serious complication with an underestimated prevalence in light of the few cases reported in the surgical literature. Three cases of CBD injury were referred to a multidisciplinary specialized gastrointestinal unit for management over a 4-year period. Anomalous anatomy, adhesions, and potential duodenal shortening secondary to contracture all predispose the biliary ducts to intraoperative injury. The axial nature of the blood supply to the extrahepatic ducts and the tendency of bile itself to cause rapid collagen turnover and fibrosis, combined with the inflammation and subsequent fibrosis to the surrounding tissues caused by bile leakage, give the bile ducts a high propensity for stricture formation. Frequently presenting symptoms of CBD injury immediately after surgery include jaundice, elevated bilirubin values, elevated t-tube drainage, and symptoms of sepsis. The most common complaints noted in patients who present in a delayed manner are symptoms of cholangitis. Even when injuries are rapidly identified and corrected, the potential for lasting negative impact on quality of life is great in many cases. When CBD injury occurs, the pancreatic duodenal union can be concomitantly disrupted.

Endoscopic Retrograde Cholangiopancreatography Gut Perforations: When to Wait! When to Operate!

Most perforations of the gastrointestinal tract during endoscopic retrograde cholangiopancreatography (ERCP) can be managed nonoperatively. Identifying patients who require operative management is problematic. A clinical endoscopy database was queried for patients who sustained ERCP perforation over a 13-year period. Records were reviewed and analyzed with approval of the Institutional Review Board. During the study period, 12,817 patients underwent ERCP; 24 (0.2%) had an endoscopic perforation. Twelve patients had a retroperitoneal perforation during sphincterotomy and all were successfully managed nonoperatively. Nine of these were undergoing treatment for sphincter of Oddi dysfunction. Twelve patients had perforation remote from the papilla. Of these, 10 required surgical intervention. Six patients had surgically altered anatomy (three postpancreaticoduodenectomy, three post-Billroth II gastrectomy) and one had situs inversus. Six of these seven required surgical intervention. Median length of stay of all patients was 7.5 days, morbidity was 25 per cent, and one patient died 16 days after surgery. Gut perforation after ERCP requires prompt surgical evaluation. Patients with sphincterotomy-related retroperitoneal perforation can be managed safely with nonoperative therapy in most instances. Patients with remote perforation usually need surgical intervention. Altered foregut anatomy leads to injuries that usually require operative management.

Endoscopic retrograde cholangiopancreatography gut perforations: when to wait! When to operate!

Most perforations of the gastrointestinal tract during endoscopic retrograde cholangiopancreatography (ERCP) can be managed nonoperatively. Identifying patients who require operative management is problematic. A clinical endoscopy database was queried for patients who sustained ERCP perforation over a 13-year period. Records were reviewed and analyzed with approval of the Institutional Review Board. During the study period, 12,817 patients underwent ERCP; 24 (0.2%) had an endoscopic perforation. Twelve patients had a retroperitoneal perforation during sphincterotomy and all were successfully managed nonoperatively. Nine of these were undergoing treatment for sphincter of Oddi dysfunction. Twelve patients had perforation remote from the papilla. Of these, 10 required surgical intervention. Six patients had surgically altered anatomy (three postpancreaticoduodenectomy, three post-Billroth II gastrectomy) and one had situs inversus. Six of these seven required surgical intervention. Median length of stay of all patients was 7.5 days, morbidity was 25 per cent, and one patient died 16 days after surgery. Gut perforation after ERCP requires prompt surgical evaluation. Patients with sphincterotomy-related retroperitoneal perforation can be managed safely with nonoperative therapy in most instances. Patients with remote perforation usually need surgical intervention. Altered foregut anatomy leads to injuries that usually require operative management.

Sphincter of Oddi dysfunction after Roux-en-Y gastric bypass

BACKGROUND

Patients who have undergone Roux-en-Y gastric bypass for morbid obesity may develop postoperative abdominal pain disorders that require surgical evaluation. Chronic pancreatitis and pain associated with sphincter of Oddi dysfunction (SOD) is an uncommon disorder whose clinical diagnosis is problematic without sphincter of Oddi manometry. To evaluate the diagnosis and treatment of SOD in the gastric bypass population, a retrospective review and analysis of gastric bypass patients who had undergone transduodenal sphincteroplasty (TS) for SOD was undertaken.

METHODS

The medical records of patients who had undergone TS after gastric bypass at the Medical University of South Carolina Digestive Disease Center from January 2002 to December 2006 were evaluated for outcomes-based data with the approval of the institutional review board for the evaluation of human subjects. Long-term patient outcomes were assessed using the Medical Outcomes Study Short Form 36-item, version 2, quality-of-life survey.

RESULTS

A total of 16 women (median age 49 years) were identified who had undergone TS with biliary sphincteroplasty and pancreatic ductal septoplasty for SOD. The indications for surgery included pain (100%), nausea (31%), weight loss (13%), and recurrent pancreatitis (31%). The diagnosis of SOD was supported by magnetic resonance cholangiopancreatography with secretin stimulation. Three postoperative complications (18.8%) developed, but no mortality. The average length of hospital stay was 5 days (range 2-9). Of the 16 patients, 13 (81%) responded to the survey follow-up. The mean length of follow-up was 28 months (range 16-57). Of the 13 patients, 11 (85%) reported pain improvement after surgery. The survey's norm-based scores were similar to those of a representative population.

CONCLUSION

SOD should be considered in the differential diagnosis of gastric bypass patients with pancreatobiliary pain after cholecystectomy. When the clinical history is supported by laboratory and magnetic resonance cholangiopancreatography data, TS can be undertaken with low morbidity and good patient outcomes. SOD is a notable disorder in the gastric bypass population. With appropriate patient selection, TS can be beneficial.

Impact of total pancreatectomy with islet cell transplant on chronic pancreatitis management at a disease-based center

Because of poor outcomes with traditional surgical management, total pancreatectomy with autologous islet transplantation (TPAIT) has been heralded as a breakthrough in the management of severe chronic pancreatitis intractable to medical management. To assess the impact of TPAIT on a pancreatobiliary disease-based center, a retrospective review and analysis of patients who underwent TPAIT after failing traditional surgical management was undertaken. Seven patients who underwent TPAIT were identified. Patient hospitalizations, emergency department visits, and clinic visits in the year pre- and post-TPAIT were tabulated. Average body weights and serum prealbumin were recorded during the year pre- and post-TPAIT. Based on the number of hospitalizations, clinic visits, and emergency department visits as an indicator of overall symptom severity, patients experienced an improvement in symptoms during the 12 months after TPAIT. Prealbumin values remained stable during the postoperative year. An observed decrease in weight suggests that other factors may be impacting the overall state of nutrition. The impact of TPAIT on the surgical management of chronic pancreatitis is limited in scope and benefit and continues to require careful analysis to identify appropriate candidates.

The Practice of Pancreatic Resection after Roux-en-Y Gastric Bypass

The morbid obesity epidemic in the United States has resulted in increasing numbers of patients who have undergone Roux-en-Y gastric bypass who require surgical management of nonbariatric disorders. When pancreatic resection is indicated in bariatric patients, consideration of the altered foregut anatomy can be applied to the principles of pancreatic resection to foster effective techniques that minimize operative complications. A retrospective review and analysis of bariatric patients who underwent pancreatic resection at the Medical University of South Carolina Digestive Center over a 2-year period (2006 to 2007) was conducted to assess indications for operation, operative techniques, and postoperative outcome in patients with previous Roux-en-Y gastric bypass. There were five patients (four female, one male) identified with a mean age of 35 years (range, 32–50 years). The mean time interval from gastric bypass to pancreatic resection was 42.6 months (range, 10–72 months). Indications for pancreatic operations were islet hyperplasia in two patients, chronic pancreatitis in two, and serous cystadenoma in one. Two patients underwent duodenal-preserving pancreatic head resection (Beger procedure) and three underwent distal pancreatectomy and splenectomy. Mean length of hospital stay was 11.4 days (range, 5–22 days). Two patients had extended hospital stay as a result of gastrointestinal ileus. There was no other operative morbidity or mortality. Mean length of patient follow up was 9.8 months (range, 1–17 months). Specific operative techniques used in pancreatic head resection were duodenal preservation, pancreatic drainage with an omega loop constructed from a mid-Roux limb, and excluded stomach gastrostomy. Techniques used in pancreatic tail and body resection were splenectomy discontinuous from pancreatectomy, division of the splenic vein and artery at the pancreatic neck early in surgery, retrograde dissection of the pancreas body and tail, and dissection of the body and tail posterior to the Roux limb leaving the Roux limb intact. Pancreatic resection after Roux-en-Y gastric bypass is safe and effective when using prescribed operative principles that minimize disruption of the foregut reconstruction and adds protection to the gastric remnant with a gastrostomy for decompression and access for enteral alimentation when necessary.

The practice of pancreatic resection after Roux-en-Y gastric bypass

The morbid obesity epidemic in the United States has resulted in increasing numbers of patients who have undergone Roux-en-Y gastric bypass who require surgical management of nonbariatric disorders. When pancreatic resection is indicated in bariatric patients, consideration of the altered foregut anatomy can be applied to the principles of pancreatic resection to foster effective techniques that minimize operative complications. A retrospective review and analysis of bariatric patients who underwent pancreatic resection at the Medical University of South Carolina Digestive Center over a 2-year period (2006 to 2007) was conducted to assess indications for operation, operative techniques, and postoperative outcome in patients with previous Roux-en-Y gastric bypass. There were five patients (four female, one male) identified with a mean age of 35 years (range, 32-50 years). The mean time interval from gastric bypass to pancreatic resection was 42.6 months (range, 10-72 months). Indications for pancreatic operations were islet hyperplasia in two patients, chronic pancreatitis in two, and serous cystadenoma in one. Two patients underwent duodenal-preserving pancreatic head resection (Beger procedure) and three underwent distal pancreatectomy and splenectomy. Mean length of hospital stay was 11.4 days (range, 5-22 days). Two patients had extended hospital stay as a result of gastrointestinal ileus. There was no other operative morbidity or mortality. Mean length of patient follow up was 9.8 months (range, 1-17 months). Specific operative techniques used in pancreatic head resection were duodenal preservation, pancreatic drainage with an omega loop constructed from a mid-Roux limb, and excluded stomach gastrostomy. Techniques used in pancreatic tail and body resection were splenectomy discontinuous from pancreatectomy, division of the splenic vein and artery at the pancreatic neck early in surgery, retrograde dissection of the pancreas body and tail, and dissection of the body and tail posterior to the Roux limb leaving the Roux limb intact. Pancreatic resection after Roux-en-Y gastric bypass is safe and effective when using prescribed operative principles that minimize disruption of the foregut reconstruction and adds protection to the gastric remnant with a gastrostomy for decompression and access for enteral alimentation when necessary.

Transduodenal sphincteroplasty in the management of sphincter of Oddi dysfunction and pancreas divisum in the modern era

BACKGROUND

Surgical management of sphincter of Oddi dysfunction and pancreas divisum is controversial. In the modern era of therapeutic endoscopy, pain persisting despite endoscopic sphincterotomy and anatomy that makes the ampulla endoscopically inaccessible prompt referral for surgical transduodenal sphincteroplasty (TS). A retrospective review of sphincter of Oddi dysfunction and pancreas divisum patients who underwent TS for refractory pain in a recent time period was undertaken.

STUDY DESIGN

The medical records of all patients who underwent TS for sphincter of Oddi dysfunction and pancreas divisum at the Medical University of South Carolina between January 2001 and December 2005 were reviewed. Longterm outcomes were assessed by a standardized written questionnaire and the SF-36 version 2 Quality of Life Survey.

RESULTS

Sixty-eight patients underwent TS (median age 43 years, 54 women). Fifty-one had earlier endoscopic sphincterotomy; 17, with previous gastric surgery, did not. Operative morbidity was 10.3%, with no mortality. Forty-five patients (66%) completed the questionnaire; 62% had improvement in pain, without reintervention, over a median followup of 42.5 months (range 16 to 75 months). There was a trend toward more favorable outcomes in patients with earlier gastric surgery (no previous endoscopic sphincterotomy) compared with others (90% versus 54%, p=0.06). Multivariate analysis showed chronic pancreatitis (odds ratio 0.11 [95% CI 0.02 to 0.68; p=0.02]) and younger age (odds ratio 3.9 [95% CI 1.32 to 11.53; p=0.01] per decade) were independent predictors of poorer outcomes.

CONCLUSIONS

Good longterm outcomes with low operative morbidity can be obtained with TS in selected patients, including those with postgastric bypass, but younger age and chronic pancreatitis appear to predict poorer outcomes.

Modulation of [3H]quinpirole binding at striatal D2 dopamine receptors by a monoamine oxidaseA-like site: evidence from radioligand binding studies and D2 receptor- and MAO(A)-deficient mice

[3H]Quinpirole is a dopamine agonist with high affinity for the D2 and D3 dopamine receptors. A variety of monoamine oxidase inhibitors (MAOIs) inhibit equilibrium binding of [3H]quinpirole binding in rat striatal membranes suggesting that MAOIs interact with a novel binding site that is labeled by [3H]quinpirole or that allosterically modulates [3H]quinpirole binding. To determine whether the D2 receptor is essential for [3H]quinpirole binding and/or modulation of [3H]quinpirole binding by MAOIs, D2 receptor-deficient mice were studied. [3H]Quinpirole binding was decreased in D2 receptor-deficient mice to 3% of that observed in wild-type controls indicating that [3H]quinpirole binding is associated with the D2 dopamine receptors. Then, in an attempt to label the site mediating the modulation of [3H]quinpirole binding, binding of the MAOI [3H]Ro 41-1049 was characterized in rat striatal membranes. [3H]Ro-41-1049 labeled a single binding site with a pharmacological profile with respect to MAOIs that was similar to both [3H]quinpirole binding (Spearman r=0.976) and MAO(A) activity. To determine whether MAO(A) plays a role in the modulation of [3H]quinpirole binding by MAOIs, MAO(A)-deficient mice were examined. In these mice, [3H]Ro-41-1049 binding was decreased to 7% of wild-type control. [3H]Spiperone binding was unaltered. Spiperone-displaceable [3H]quinpirole binding was decreased to 43% of wild-type control; however, the remaining [3H]quinpirole binding in MAO(A)-deficient animals was inhibited by Ro 41-1049 similar to wild-type. [3H]Ro-41-1049 binding was not decreased in D2 receptor-deficient mice. These data suggest that [3H]Ro-41-1049 labels multiple sites and that MAOIs modulate [3H]quinpirole binding to the D2 receptor via interactions at a novel, non-MAO binding site with MAO(A)-like pharmacology.

Lead toxicosis and trace element levels in wild birds and mammals at a firearms training facility

In May 1999, lead poisoning was diagnosed in a yellow-rumped warbler (Dendroica coronata) and a gray squirrel (Sciurus carolinensis) found at the Federal Law Enforcement Training Center (FLETC), Glynn County, GA, based on detection of 6.2 and 90.0 ppm wet weight (WW) lead in the liver of the warbler and squirrel, respectively. From October 21--26, 1999, 72 wild animals (37 mammals and 35 birds), comprised of 22 different species, were collected from a 24-ha area surrounding the FLETC outdoor firearms shooting range complex to evaluate exposure to lead and other trace elements. Ten animals were used as controls (five mammals and five birds) and were collected from areas 1.5--3 km outside the shooting range area. Kidney and liver tissues were analyzed for lead, zinc, and other trace elements. Bird gizzards and white-tailed deer abomasums were examined grossly and radiographically to detect metallic objects. Twenty-four (33.3%) animals (11 species) had kidney or liver tissue lead levels > 1.00 ppm, and 12 of these (6 species) had levels > 2.00 ppm. Carcasses of one brown-thrasher (Toxostoma rufum) and two white-tailed deer (Odocoileus virginianus) contained lead fragments. Elevated liver tissue levels of zinc (111.0 ppm) were detected in one brown thrasher that also had elevated kidney and liver tissue lead levels. In February 2000, seven yellow-rumped warblers and one solitary vireo (Vireo solitarius) found dead near the FLETC firearms shooting range also were diagnosed with lead poisoning, with liver and kidney tissue lead levels from 1.77--11.6 and 4.55--17.8 ppm WW, respectively. This frequency of elevated tissue lead levels among the animals examined, in combination with confirmed lead toxicosis in both avian and mammalian species at FLETC, indicates significant lead exposure of local wild bird and mammal communities via bullets and fragments in and on the soil surface of the four outdoor ranges. Most FLETC firearms training is being shifted to new baffled ranges (four walls with semiopen top) with bullet recovery capabilities to preclude future deposition of lead in the environment; existing outdoor ranges will be remediated to remove existing lead.

Characteristics and outcomes of a home and community-based neurorehabilitation programme

The potential clinical and financial advantages of providing neurorehabilitation directly in patients' homes and communities have recently been discussed. However, the specific characteristics and outcomes of a coordinated, interdisciplinary, home-based programme does not currently exist in the rehabilitation literature. The present paper presents patient demographics, type and intensity of services provided, satisfaction measures, and clinical outcomes for 77 brain injured individuals in an attempt to begin to define and evaluate this new level of care. Additionally, the challenges of conducting home-based rehabilitation, and needs for further research are discussed.

Binding of [3H]PD 128907, a putatively selective ligand for the D3 dopamine receptor, in rat brain: a receptor binding and quantitative autoradiographic study

[3H]PD 128907 has been proposed as a selective ligand for the D3 dopamine receptor. This study characterizes the binding of this radioligand in rat brain using in vitro radioligand binding and autoradiographic methods. In radioligand binding studies, [3H]PD 128907 exhibited 0.3 nmol/L affinity for a single, low density site in ventral striatal membranes. The pharmacological profile for [3H]PD 128907 was similar to that of [3H](+)-7-OH-DPAT with the rank order of potency for dopamine agonists being PD 128907 approximately 7-OH-DPAT approximately quinpirole > or = dopamine; for antagonists, spiperone > (+)-butaclamol approximately domperidone > or = haloperidol > SCH 23390. Guanyl nucleotides had no effect on the binding of either ligand. These observations indicate labeling of a dopaminergic site with characteristics consistent with the D3 receptor. In autoradiographic studies, highest densities of [3H]PD 128907-labeled sites were observed in islands of Calleja followed by the nucleus accumbens, nucleus of the horizontal limb of the diagonal band, the molecular layer of cerebellar lobule X, and the ventral caudate/putamen.

Modulation of [3H]quinpirole binding in brain by monoamine oxidase inhibitors: evidence for a potential novel binding site

[3H]Quinpirole is a dopamine agonist with high affinity for the D2 and D3 dopamine receptor subtypes. A variety of drugs, most notably monoamine oxidase inhibitors (MAOls), inhibit the binding of [3H]quinpirole, but not [3H]spiperone or [3H](-)N-n-Propylnorapomorphine, in rat striatal membranes by a mechanism that does not appear to involve the enzymatic activity of MAO. This study extends the characterization of MAOI-displaceable [3H]quinpirole binding in rat brain. Clinically antidepressant MAOIs exhibited selectivity between sites labeled by [3H]quinpirole and [3H]spiperone as did a number of structurally related propargylamines and N-acylethylenediamine derivatives and other drugs such as debrisoquin and phenylbiguanide. The MAOIs clorgyline and Ro 41-1049 were the most potent. Anti-depressant MAOIs inhibited [3H]quinpirole binding with the following rank order of potency: phenelzine > pargyline > tranyl-cypromine > isocarboxazid > nialamide > moclobemide. In striatal membranes, MAOI Ro 41-1049 inhibited [3H]quinpirole binding with similar potency at a variety of incubation temperatures (4-37 degrees C), assay tissue concentrations (5-20 mg original wet weight/ml), and time points (2 min-4 hr) and in the presence or absence of K+, Mg2+, Ca2+ ions, ascorbate, EDTA and NaCl. The regional distribution of Ro 41-1049-displaceable [3H]quinpirole binding in brain paralleled that of D2-like receptors. These data suggest that MAOIs interact with a novel binding site that is labeled by [3H]quinpirole or that modulates [3H]quinpirole binding. This site may be associated with D2-like dopamine receptors.

Interdisciplinary roles in stroke care

Care of the stroke patient presents a complex challenge to the interdisciplinary stroke team. The physical therapist, occupational therapist, and clinical social worker are important members of that team, each of whom contributes specialized knowledge and interventions in behalf of the patient. The physical therapist focuses on prevention of joint and tissue injury and retraining of lost motor skills. The occupational therapist considers the total patient in his or her environment and assists the patient in regaining or improving function in all areas of daily living. The clinical social worker concentrates on psychosocial assessment and intervention with the patient and family, aiding them in the adjustment process and planning for discharge. The nurse, in addition to playing a unique role in the delivery of nursing care to the stroke patient, is in a position to serve as coordinator of the interdisciplinary team. The nurse can facilitate the work of the physical and occupational therapists and the social worker by providing them with timely referrals, valuable assessment information and insights, and reinforcement of therapeutic activity while the patient is on the nursing unit. The keys to making the interdisciplinary team work for the maximal benefit of the patient are threefold: mutual respect and understanding among team members; ongoing coordination of efforts; and open communication between all team members, the patient, and the family. These elements are interrelated and essential if the interdisciplinary team is to be successful at meeting its ultimate goal: expert care of the total patient to achieve maximal independence.