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Objectives: To determine the immunologic consequences of nonlethal hemorrhage on subsequent exposure to lipopolysaccharide (LPS) and to determine the role of interleukin 1 beta (IL-1) specifically in mediating the response to LPS with and without prior hemorrhage., Design: Prospective, randomized, controlled experimental trial., Participants: Male BALB/c mice and transgenic mice deficient in IL-1 converting enzyme., Interventions: Animals were subjected to hemorrhage (by cardiac puncture), LPS challenge by intraperitoneal injection, or hemorrhage followed 24 hours later by LPS challenge. Mortality was assessed every 4 hours for 96 hours following hemorrhage or LPS exposure. Serum IL-1 levels were determined 24 hours after exposure to hemorrhage and LPS., Setting: University of South Florida Core General Surgery Research Facility, Tampa., Main Outcome Measures: Mortality and serum IL-1 levels., Results: Hemorrhage alone resulted in complete survival, whereas LPS alone resulted in near-complete (95%) mortality. Hemorrhage, when given 24 hours before LPS challenge, afforded significant protection compared with LPS alone (67% survival vs 5% survival; P < .001). Serum IL-1 levels 24 hours after exposure to LPS were significantly lower in prehemorrhaged mice than in those receiving LPS alone. Transgenic mice incapable of producing biologically active IL-1 were further protected, demonstrating near-complete (95%) survival following hemorrhage and LPS challenge., Conclusions: Cytokine activation through nonlethal hemorrhage attenuates subsequent IL-1 response to early immunologic challenge. Such immune suppression appears to be protective early on and is supported by the near-complete immunity to LPS in animals incapable of producing biologically active IL-1.

Clinical observations and data obtained in animal experiments indicate that the gastric partition is most susceptible to the stresses of solid food boluses between the second and sixth postoperative weeks, predisposing the operation to early failure. Tensiometer studies indicate that by the sixth to the eighth postoperative week, the staple line is as strong as uninjured stomach. Liquid diet restriction for eight weeks after gastric partitioning reduces the incidence of early operative failure. Until safe and effective methods of increasing staple line strength are established, all patients having gastric partitioning should be restricted to a liquid diet for eight weeks after operation.

The hemodynamic effect of pancreatic ascitic fluid was studied in a porcine model. Pancreatitis was induced by a low-pressure infusion of trypsin and taurocholate sodium into the pancreatic duct. The ascitic fluid that accumulated was then injected into the inferior vena cava of five pigs, with each pig receiving five infusions at 40-minute intervals. Mean arterial blood pressure and peripheral vascular resistance fell with each infusion, while pulmonary artery pressure increased. The magnitude of the drop in arterial blood pressure decreased with subsequent infusions, suggesting tachyphylaxis. The rise in pulmonary artery pressure increased with successive infusions. Anesthesia artifact and decay of the pancreatic ascitic fluid were ruled out as causes of the tachyphylaxis. Filtration separated the substances producing pulmonary effects and systemic blood pressure effects (0.2 to 11 microns vs 10,000 daltons to 0.2 micron). These data suggest that two mediators may produce the hemodynamic effects of pancreatic ascitic fluid.

We examined the risk factors for the development of local recurrence in patients treated with a conservative wide local excision, which was defined as being less than the historical 5-cm margin. There were 118 patients with clinical stage I disease followed up for a minimum of 60 months or until death. The extent of wide local excision varied from 0.6 to 8.5 cm. The majority (76.3%) had a resection margin of 30 mm or less. Four patients (3.4%) had local recurrence within 5 cm of the primary closure scar or skin graft edge. The primary lesion in the patients with local recurrence had deeper invasion and larger diameters than the lesion in patients who did not have local recurrence. Other recognized risk factors, such as ulceration, satellitosis , and unrecognized subclinical stage II disease, at the time of initial diagnosis were noted in the patients eventually displaying local recurrence. Tumor aggressiveness was recognized. The patients who had local recurrence had excisions with wider margins (mean, 4.75 cm; range, 2.5 to 8.5 cm) than the patients without local recurrence (mean, 2.87 cm; range, 0.6 to 6.0 cm). A tumor-field effect did not contribute to local recurrence.

Forty-two patients with the postcholecystectomy syndrome were studied by endoscopic retrograde cholangiopancreatography (ERCP). Both the biliary ductal system and pancreatic duct were well visualized in all patients. The ERCP was abnormal in 22 patients (52%). Abnormal findings included choledocholithiasis, papillary stenosis, pancreas divisum, pancreatic carcinoma, sclerosing cholangitis, incomplete cholecystectomy, and chronic pancreatitis. The results of one or more standard liver function tests and/or other noninvasive tests were abnormal in 36 patients; however, none reliably predicted the presence or specific anatomical type of pancreaticobiliary tract disease. Our data indicate that ERCP is essential in the diagnosis and management of the postcholecystectomy syndrome. The high yield of abnormal findings amenable to surgical correction in patients with recurrent biliary tract symptoms following cholecystectomy justifies the use of this procedure in all such patients.

A permanent feeding gastrostomy was quickly and simply constructed in 29 patients with low operative risk using the gastrointestinal anastomotic stapler. The technique consisted of a simple application of this stapler on a carefully selected section of the stomach to form a Janeway type of gastrostomy. Activation of the device placed two double rows of staples and cut between them. This left the mucosa in approximation both in the tube and in the body of the stomach. A few additional Lembert sutures was all that was necessary. There were no suture line leaks nor other complications peculiar to the method.

During the last three decades, 2,4117 splenectomies have been performed at The Ohio State University Hospital. Indications for splenectomy include hypersplenism, incidental to other abdominal procedures, trauma, Hodgkin's staging, and other splenic disease. Hodgkin's staging has become the most frequent indication for splenectomy during the past five years, whereas splenectomy for hypersplenism has decreased. Thrombocytosis (platelet counts greater than 400,000/cu mm) was observed in 47% of all patients. Ninety-three percent of all thromboembolic complications occurred in this group. The overall morbidity of 39% has been decreased to 15% during the last five years. In-hospital mortality has decreased from 9.5% to 6%. Incidental splenectomy, even for benign disease, continues to be associated with complications and death.