Barr, Darlene

Currently in pancreas transplantation, only indirect evidence of graft dysfunction is used as the mainstay of diagnosing a rejection episode. However, histologic specimens obtained by open surgical procedures are required for diagnostic dilemmas. After demonstrating the safety and efficacy of a cystoscopically‐directed biopsy technique to obtain adequate histologic specimens in a canine pancreaticoduodenal allograft model, we began using a similar technique in our human recipients. Between December 1987 and January 1989, 16 patients received a pancreaticoduodenal allograft with a duodenocystostomy at the Mayo Clinic. Cystoscopically‐directed needle biopsy specimens of the pancreas were obtained at the time of graft dysfunction (hypoamylasuria) and at 10 days after transplantation. The biopsy procedure consisted of obtaining pancreatic core tissue specimens with an 18‐gauge Menghini biopsy needle introduced through a rigid side‐viewing néphroscope that had been inserted transurethrally through the urinary bladder into the transplanted duodenal segment. The specimens were identified to be adequate histologically if acinar tissue was present. Each biopsy procedure was followed closely by clinical and ultrasonic examinations and serum amylase determinations. In 12 recipients, we performed 23 cystoscopically‐directed biopsies and 14 specimens (61%) were adequate. However, of our last 13 biopsy specimens, 12 (92%) were adequate. The follow‐up time per biopsy was an average of 103 d (range, 4 to 290 d). We had only two complications. Both were episodes of moderate hematuria that resolved with less than 24 hours of urinary catheter drainage. No fistulae, pseudocysts, hematomas, episodes of pancreatitis, or infections related to the biopsy procedure were documented. We have demonstrated that the cystoscopically‐directed biopsy technique is a safe procedure in human pancreaticoduodenal transplantation. This procedure can be used to differentiate the many causes of graft dysfunction.

The importance of portal insulin delivery in the regulation of postprandial carbohydrate metabolism is uncertain. To address this question, three groups of dogs were studied: one group in which pancreatic venous drainage was transected and reanastomosed (portal insulin delivery), one in which the pancreatic drainage was transected and anastomosed to the inferior vena cava (peripheral insulin delivery), and one that received only a sham operation. Plasma insulin was greater (P < 0.05) during peripheral insulin delivery than in either the portal or sham groups, respectively, before and after meal ingestion. On the other hand, C-peptide concentrations did not differ between groups, resulting in a higher (P < 0.001) insulin to C-peptide ratio in the peripheral group. This indicated that the hyperinsulinemia in the peripheral group was due to decreased insulin clearance rather than increased insulin secretion. Isotopically determined splanchnic uptake of ingested glucose, postprandial suppression of hepatic glucose release, incorporation of CO2 into glucose (a qualitative measure of gluconeogenesis), and total-body glucose uptake were virtually identical in all groups. Similarly, plasma lipid, β-hydroxybutyrate, and lactate concentrations did not differ between groups. Our data indicate that, despite differences in systemic insulin concentration, portal and peripheral insulin delivery comparably regulate hepatic and extrahepatic carbohydrate metabolism after meal ingestion.

AbstractDuring the period 1979 to 1989, 0.1 % of all cases of acute appendicitis at our institution occurred soon after another operative procedure. The interval between primary operation and appendectomy was 5 to 31 days (mean, 14 days). Signs and symptoms did not differ from those of classical acute appendicitis. Duration of symptoms ranged from 12 hours to 8 days (mean, 2.4 days). Perforation was present in 3 patients, suppurative appendicitis in 1 patient, and acute inflammation in 4 patients. Two of the perforations were associated with abscess formation. Morbidity related to the appendiceal condition included hepatic abscesses, septic shock, and prolonged ileus. There was no mortality. Hospitalization ranged from 6 to 80 days (mean, 12.5 days).

Abstract The ability to differentiate benign from malignant Hürthle cell thyroid neoplasms has provoked considerable controversy. This has significant therapeutic implications, since some have advocated total thyroidectomy for all of these lesions. The principal objectives of this study were: (a) to determine whether the histologic diagnosis of Hürthle cell adenoma could be reliably made, (b) to quantitate the risk of inappropriately labelling a Hürthle cell cancer as an adenoma, and (c) to ascertain whether the type of operative procedure affected the clinical course . We reviewed 272 patients who had undergone thyroid resection for benign Hürthle cell neoplasms at the Mayo Clinic from 1960 to 1980. All pathologic sections were rereviewed. Postoperative follow‐up was available on 233 patients (86%), with a mean of 8.9 years. A minimum of 5 years of follow‐up was obtained on 10% of the patients. Nodules ranged in size from 0.3 to 11 cm; 195 (55%) were 2 cm or larger. Surgical resection was limited to one side in 137 (50%) patients and involved both sides in 135 patients. No total thyroidectomies were performed. Evidence of malignancy—a local recurrence—developed in only 1 patient, and she died of unrelated causes. None of the 272 patients died of thyroid cancer, and none showed evidence of metastases. Our data is in agreement with most published reports, with only 6 (0.9%) of 642 reported patients being diagnosed incorrectly. These tumors can be accurately separated into benign and malignant. Routine total thyroidectomy for Hürthle cell adenomas is not justified .