Biliary sludging in critically ill trauma patients

We used serial weekly ultrasonography to prospectively screen 19 critically ill trauma victims for the development of biliary sludge. Fourteen patients had sludge formation during their hospitalization. Sludge development was positively associated with increased transfusion requirements, but not with any other laboratory or clinical findings, including injury severity scores. The enteral feedings administered to most patients did not prevent sludge formation in the majority of cases; all five patients receiving total parenteral nutrition had sludge. Three patients had complications that could possibly be attributed to the sludge (one case of acalculous cholecystitis and two cases of mild pancreatitis). No such problems occurred in the five patients who did not have sludge. No long-term clinical problems related to sludge have occurred. We conclude that gallbladder sludge frequently develops in critically ill trauma patients and that sludge may be associated with pancreatobiliary complications.

The ramifications of immediate reconstruction in the management of breast cancer

A retrospective review of 50 patients who underwent immediate postmastectomy breast reconstruction was performed to determine the effect of reconstruction on the treatment of these patients. The overall complication rate was 50% (25 of 50). Smoking statistically correlated with an increased rate of wound complications (0 = 0.0001). Obese patients had nearly twice as many wound complications; however, this finding was not statistically significant (P = 0.261). Eleven of the 50 patients underwent reconstruction with a prosthesis, with an overall complication rate of 64% (seven of 11) and a 55% (six of 11) rate of prosthesis loss. Thirty-nine of the 50 patients underwent reconstruction with autologous tissue. Forty-six per cent (18 of 39) of the patients in the autologous group developed complications, and eight required emergent reoperation to prevent flap loss. The wound complication rate was significantly lower for bipedicled transverse rectus abdominis muscle (TRAM) flap reconstructions than for other forms of autologous reconstruction (P = 0.040). total operative time (including mastectomy) was 3.11 hours (range, 2-4 hours) for the prosthetic group and 9.4 hours (range, 5-15 hours) for the autologous group. All but two patients undergoing autologous tissue reconstruction required blood transfusions; an average of 2.4 U of blood was transfused per patient (range, 0-7 U). Only two patients in the prosthetic group required a transfusion. The average hospital stay was 5 days (range, 2-7 days) for the prosthetic group and 8.3 days (range, 5-19 days) for the autologous tissue group.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of the tram and latissimus dorsi flaps in autogenous breast reconstruction

Breast cancer has reached near epidemic proportions in this country. It is a devastating blow to the patient and her family. Refinements in breast reconstruction have aided greatly in alleviating this harsh attack on the patient's well being and femininity. Many modalities have been used in the past to achieve breast reconstruction but the use of autogenous tissue and immediate reconstruction have permitted the plastic surgeon the opportunity to regain the normal shape of the breast and at times even obtain an improved aesthetic result. We are still not able to obtain a reconstructed breast that has normal sensation and erogenous stimulation. Patients, however, are demanding more and more of their surgeons as they try to better adapt to their conditions. It is hoped that with the advent of new health care reform these patients will not be deprived of the meaningful advances that have been made to date in this field. To paraphrase a saying attributed to Tagliacozzi: "Our objective is not merely to stamp out disease but it is also to buoy the spirit of the afflicted."

Proliferation-associated nucleolar antigen P120: a prognostic marker in node-negative breast cancer

BACKGROUND

P120 is a nucleolar proliferation antigen found in rapidly dividing cells and in a variety of malignancies.

METHODS

Our purpose was to determine whether P120 expression is a prognostic factor for patients with node-negative breast cancer by testing pathologic material from 90 patients for P120 immunoreactivity, histologic grade, and estrogen receptors.

RESULTS

P120 was detected in 52 of the 90 specimens (58%). Node-negative cancer patients with tumors that did not express the P120 antigen had a significantly better overall survival rate than node-negative cancer patients with tumors that did express P120 (92% vs 69%; p = 0.035). Histologic studies indicated that 36 tumors were grade I, 28 were grade II, and 26 were grade III. The presence of P120 correlated significantly with the nuclear grade of the tumor: 73% of grade III tumors, 64% of grade II tumors, and 42% of grade I tumors stained positive for P120 (p = 0.033). The correlation between nuclear grade and overall survival rate was also significant (grade 1, 94%; grade II, 79%; grade III, 58%); (p = 0.003). No significant correlation was found between P120 expression and estrogen receptors. Multivariate analysis shows that P120 expression and histologic grade together are the strongest predictors of survival.

CONCLUSIONS

The biologic marker P120 may play an important role in determining which patients with node-negative cancer will benefit most from adjuvant therapy.

Prospective study correlating P120 antigen expression with established prognostic factors in breast cancer

P120 is a nucleolar proliferation antigen found in rapidly dividing cells and a variety of malignancies. Previous retrospective studies have demonstrated that, when detected in human breast cancer, P120 is associated with a poorer prognosis. To determine whether P120 expression correlates with other prognostic factors in breast cancer, we prospectively analysed pathologic and clinical data from 61 patients. P120 was detected in 40 of the 61 specimens (66%). No significant correlation existed between P120 expression and either tumour size or hormone receptors. A significant correlation was found between P120 expression and histological grade, degree of aneuploidy, S-phase fraction, degree of nodal involvement, and stage of disease. P120 is a biological marker indicative of tumour aggressiveness and may play an important role in determining which patients would most benefit from adjuvant therapy.

Mirizzi's syndrome

Mirizzi's syndrome is a partial obstruction of the biliary tree caused by a stone impacted in the cystic duct, with or without development of a cholecysto-biliary fistula. We report our experience with five cases and review current methods of diagnosis and management. Preoperative diagnosis greatly facilitates management. Diagnosis may require a combination of ultrasonography, computed tomography, and cholangiography (percutaneous or endoscopic retrograde). At surgery, dissection in the triangle of Calot should be minimized to avoid injury to the common bile duct. Often, a partial cholecystectomy is the only safe option. Defects in the common bile duct can be repaired by a variety of methods. The morbidity and mortality associated with this rare syndrome can be relatively high. A number of patients may have late biliary strictures.

Necrotizing fasciitis as a complication of percutaneous catheter drainage of an intra-abdominal abscess

Computerized tomography or ultrasound-guided percutaneous drainage has replaced surgery as the preferred method of treatment for intra-abdominal abscesses and is generally regarded as safe. The authors, however, report a case of necrotizing fasciitis complicating percutaneous drainage of a postoperative intra-abdominal abscess. This potentially fatal complication illustrates that successful percutaneous drainage of an abscess does not eliminate the need to closely monitor the patient's subsequent clinical course. Successful treatment of necrotizing fasciitis depends on early recognition, radical debridement, aggressive fluid resuscitation, and diligent postoperative wound care.

Intestinal glutamine metabolism after massive small bowel resection

Gut glutamine utilization after massive small bowel resection was studied to gain further insight into the alterations and adaptations in intestinal glutamine metabolism that occur during the development of post-resectional hyperplasia. After resection of the middle 60% of the small intestine in the rat, gut glutamine metabolism was studied immediately and 1, 2, and 3 weeks later. Whole gut glutamine extraction was 22% in sham controls and it acutely declined to 12% (p less than 0.01) after bowel resection. Extraction increased to 31% 1 week later (p less than 0.05) and then returned to normal by week 2. Gut ammonia release decreased after massive small bowel resection, whereas intestinal alanine release increased. The increase in gut glutamine extraction at 1 week occurred at a time when jejunal and ileal DNA and protein content were markedly increased (p less than 0.01). Intestinal glutaminase content declined initially and then increased by the third week after bowel resection (p less than 0.01). With time, increases in gut cellularity and glutaminase content are associated with gut glutamine utilization in the shortened small bowel that is equal to that of the intact unresected intestine.