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We conducted a prospective study to validate our previous finding that serum urea and plasma glucose levels on admission could predict the outcome of acute pancreatitis. Forty-two (24%) of 176 patients developed complications related to the attack of acute pancreatitis and were classified as having severe disease. By logistic regression analysis of 17 admission parameters, serum urea and plasma glucose levels were again the factors with independent significance in defining the outcome. By adopting the same cutoff levels as in our previous study (serum urea level greater than 7.4 mmol/L and plasma glucose level greater than 11.0 mmol/L), and the presence of either factor above the cutoff level as indicative of severe disease, the sensitivity of prediction was 79%, specificity 67%, and overall accuracy 70%. All the deaths were correctly predicted by this urea/glucose criteria. The overall accuracy was also found to be comparable with those of the APACHE II (cutoff level greater than 11) and Ranson's scoring systems. We conclude that the simple prognostic criteria for acute pancreatitis were validated; these criteria have the potential to stratify risk rapidly at the time of admission for patients who might benefit from an aggressive interventional protocol.

Clinical data from 50 consecutive patients with unresectable hilar tumors situated at or proximal to the common hepatic duct were retrospectively analyzed to aid in the selection of appropriate palliative measures. Thirty-four patients had cholangioenteric bypass (CEB) to either left (28 patients), right (3 patients), or both (3 patients) intrahepatic ductal systems. Sixteen patients had nonoperative drainage (NOD) established either endoscopically (4 patients), percutaneously (9 patients), or using a combined endoscopic-percutaneous approach (3 patients). When compared with patients with CEB, patients with NOD had more frequent medical problems (p

Probably the most frequent cause of upper gastrointestinal hemorrhage is bleeding duodenal ulcer. A prospective study was undertaken of 433 patients admitted to the hospital with bleeding duodenal ulcer, in order to determine the optimum timing and role of surgery and/or therapeutic endoscopy (visualization of an interior cavity of the body using an illuminated optic instrument). The average age of the patients was 55, and the male:female ratio was approximately 2:1. There were 12 deaths, 11 of which were among 60 years of age and older. Four of these patients had been treated conservatively (without surgery) and eight had undergone emergency operations. Ulcer size was associated with increased incidence of death. Of 288 patients who had endoscopy and initial measurement of the ulcer size, 40 patients (13.9 percent) showed evidence of rebleeding. This was associated with a higher mortality (0.4 versus 12.5). Rebleeding occurred in 13 of 186 patients (7 percent) who did not have evidence of recent hemorrhage. There were 27 patients with rebleeding out of 102 patients (26.5 percent) who did have evidence of recent hemorrhage. Of the 12 deaths, 9 were patients who had no previous history of acute gastrointestinal bleeding. Therapeutic endoscopy was performed on eight patients and all survived. Factors related significantly to outcome were previous medical illness, age greater than 60 years, being in shock at the time of admission and a low hemoglobin level at admission. The most important prognostic factor was endoscopy-documented evidence of recent hemorrhage in ulcers greater than 1 cm in diameter. (Consumer Summary produced by Reliance Medical Information, Inc.)

BACKGROUND: Hyperinsulinemia in multiple endocrine neoplasia type I (MEN-I) is a rare but potentially curable condition that presents difficulties not encountered in sporadic cases. METHODS: The present report documents our surgical approach to 3 MEN-I patients with Hyperinsulinemia. RESULTS: Primary hyperparathyroidism was manifested in all 3 patients at the time of presentation. Distal subtotal pancreatectomy with enucleation of tumor at the head of pancreas detected intraoperatively resulted in immediate cure of 2 patients. Persistent disease occurred in I patient after enucleation of tumor at the head of the pancreas guided by preoperative imaging elsewhere. The patient was subsequently cured by distal subtotal pancreatectomy. Pathology revealed multiple tumors (4 to 14) in all patients. CONCLUSIONS: A different surgical strategy with an aim of distal subtotal pancreatectomy and enucleation of any tumor identified in the head of pancreas is the treatment of choice for hyperinsulinemia in MEN-I patients. Am J Surg. 1998; 175:305-307. [C] 1998 by Excerpta Medica Inc.

Cholangitis is inflammation of the bile duct due to bacteria or obstruction caused by gallstones or tumor. The symptoms of acute cholangitis include intermittent fever, right upper abdominal pain, and jaundice (yellowing of the skin) if there is obstruction of the bile duct. Initial treatment consists of antibiotic therapy, however when infection progresses decompression of the biliary system becomes necessary. This emergency surgery has high morbidity and mortality (rates of sickness and death). To attempt to identify the patients who are at high risk for postoperative complications, a study was undertaken of 86 patients who underwent emergency biliary exploration due to gallstone obstruction of the bile duct. Prior to surgery, 55 patients were in septic shock, inadequate blood flood to the body's peripheral tissues caused by septicemia and the presence of endotoxins in the blood. All 86 patients received general anesthesia and underwent exploration of the bile duct; additional procedures performed included 55 cholecystectomies (gallbladder removal), and 7 other procedures (5 cholecystostomies, and 2 transhepatic intubations). Complications occurred in 43 patients (50 percent), and 17 patients (20 percent) died. Multivariate analysis identified five predictive factors: concomitant medical problems, and abnormalities in blood pH, total bilirubin, platelet count, and serum albumin. When three or more risk factors were present there was a significantly higher risk of morbidity and mortality than when there were fewer risk factors. These findings indicate that patients who are high surgical risks be considered for nonoperative drainage of the biliary system. (Consumer Summary produced by Reliance Medical Information, Inc.)