Biomedical subjects

A G Coran

Publications and source records attributed to A G Coran.

At least 127 records · Page 7Linked to original sources

PubMed1989

A comparison between operative and nonoperative management of blunt injuries to the liver and spleen in adult and pediatric patients.

Nonoperative management of blunt trauma involving the liver and spleen has been accepted in stable pediatric patients but has been controversial in adult patients. The purpose of this study was to compare nonoperative management of blunt liver and spleen injuries in adult patients with a similar group of adult patients treated operatively and with a group of pediatric patients treated nonoperatively. A 5-year retrospective study was carried out on all hemodynamically stable patients who came to our institution with blunt abdominal trauma. There were 20 adults treated operatively (group I), 25 adults treated nonoperatively (group II), and 34 pediatric patients treated nonoperatively (group III). The mean acute physiology and chronic health evaluation score for group I was 5.1; group II, 3.1; and group III, 7.9. Delayed splenectomy was required in four adult patients in group I and in one patient in group III. There were no deaths. The mean total blood requirement was 6.0 units for group I, 2.8 units for group II, and 1.7 units for group III. The average hospital stay was 19.1 days for group I, 12.6 days for group II, and 9.2 days for group III. These data suggest that the outcome of adult patients whose blunt liver and spleen injuries are managed nonoperatively is comparable with that of pediatric patients treated nonoperatively and is as good as that of adults undergoing early laparotomy.

Adult↗

PubMed1989

Postoperative bleeding in cardiovascular surgery. Does heparin rebound really exist?

Postoperative bleeding following cardiovascular procedures is troublesome and often life-threatening. The effect of heparin (H) is usually reversed with protamine sulfate (P) at the end of vascular procedures; subsequent bleeding or abnormal coagulation times are ascribed to so-called heparin rebound and are treated with extra empiric doses of P. H rebound has heretofore been described only by using biologic clotting tests, which are often abnormal postoperatively. Thus, many instances of postoperative bleeding are treated with inappropriate and dangerous doses of P in the mistaken impression that more H needs to be reversed. Using the new test for plasma H, the azure A Assay, which measures H chemically rather than biologically, 27 patients were tested after cardiac bypass surgery to determine whether H rebound truly exists. Azure A levels of H were measured before the bypass procedure and every half hour from 0-8 hours after bypass in routine coronary artery bypass patients. Tests for prothrombin time (PT) and partial thromboplastin time (PTT) were performed simultaneously. The azure A test was performed on 252 samples of blood in the 27 patients; only one sample drawn anytime except immediately after bypass contained measurable H (0.4%). This sample became negative for H in the ensuing 30 minutes.(ABSTRACT TRUNCATED AT 250 WORDS)

Azure Stains↗

PubMed1989

Late results of fundoplication for gastroesophageal reflux in infants and children.

The Nissen fundoplication (NFP) for the management of severe gastroesophageal reflux (GER) in infants and children has become one of the most frequently performed operations in pediatric surgical centers in the United States. Short-term outcome, morbidity, and mortality are consistently favorable in several large series. The long-term success of this procedure is presumed but has not been established objectively. To examine the late results of this operation, 46 infants and children were carefully evaluated more than 5 years after NFP (mean, 6.7 years). Evaluation included parental interview, physical examination, upper gastrointestinal series, and esophageal pH monitoring. The mean age at the time of operation was 4.13 years. Fifty-seven percent of the patients had significant neurologic impairment, and 80% had at least one serious additional medical problem. Twenty-four percent of the children died during the period of follow-up--all but one death related to serious underlying medical problems. Of the 35 survivors, 26 (74.3%) have no symptoms; five (14.3%) have mild symptoms potentially referable to GER that necessitate little if any treatment; four (11.5%) have had symptomatic recurrence of GER necessitating repeat fundoplication. Three of these patients now have no symptoms. Forty-five percent of the patients had at least one postoperative complication. NFP provides efficacious, long-term treatment of GER in infants and children, with acceptable morbidity. Mortality in this group of children is related primarily to associated diseases rather than to GER.

Adolescent↗

PubMed1988

The development of necrotizing enterocolitis following repair of gastroschisis: a surprisingly high incidence.

We recently observed the development of necrotizing enterocolitis (NEC) in two consecutive newborn infants after gastroschisis repair. Because this association was unexpected, a retrospective review of our 11-year experience was performed using a multivariant computer analysis. The cohort consisted of 54 newborns with gastroschisis. All infants with omphalocele were excluded. Ten of 54 infants (18.5%) developed NEC as defined by classical clinical findings and pneumatosis intestinalis. Twenty-one distinct episodes of NEC occurred with up to three episodes (mean, 2.1) per patient. Twenty of the 21 episodes were successfully treated nonoperatively. Two infants developed pneumoperitoneum, one of whom underwent laparotomy upon which no perforation or intestinal infarction was found. Eight of the ten patients survived--a survival rate no different than for the remainder of the study group. Neither of the two deaths was attributable to NEC. The NEC was atypical in that no significant relationship was established with known predisposing conditions such as prematurity or low Apgar scores. Suspected risk factors such as time of feeding, type of closure, type of formula, total parenteral nutrition (TPN), and composition of TPN were not statistically related. Significant associations included concurrent TPN associated cholestatic liver disease in nine of the ten infants, antecedent intestinal surgery other than abdominal wall closure in five of the ten infants, and delay in initiation of enteral feedings (greater than 30 days) in eight of ten infants. In addition, the NEC occurred significantly later (range, 32 to 79 days; mean, 52 days) in the clinical course than usual; in fact, three of ten infants were rehospitalized with NEC following discharge. We conclude that a relationship exists between NEC and gastroschisis.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal Muscles↗

PubMed1988

Oxygen free radical activity during live E. coli septic shock in the dog.

Free radicals generated during purine catabolism or by activated granulocytes cause tissue injury by peroxidation of lipid membranes. In a canine model of sepsis initiated by intravenous live Escherichia coli, fluorescent products of lipid peroxidation (FP) were measured in serum. Four groups of five dogs infused with 10(9)E. coli/kg were analyzed--I: no further treatment; II: prior depletion of granulocytes with a cytotoxic antibody; III: pre-treatment with superoxide dismutase and catalase; and IV: resuscitation after bacterial infusion to maintain cardiac output greater than 80% of pre-bacteremic levels. In Groups I, II, and III, cardiac output fell to less than 50% of baseline within 1 hr and remained there throughout the study. FP in Groups I and II rose to greater than 200% of baseline (P less than .02 and less than .03). In Groups III and IV, FP did not rise significantly from baseline. The rise in serum FP and the prevention of this rise by-treatment with antioxidants indicate generation of oxygen radicals. Their presence had no effect on hemodynamic parameters. Granulocyte depletion did not alter appearance of FP; however, prevention of low cardiac output blocked FP formation. These data suggest that oxygen free radicals were generated by tissue ischemia, rather than by granulocytes, in this model of septic shock.

Animals↗

PubMed1988

Obstructive jaundice secondary to chronic pancreatitis in children: report of two cases and review of the literature.

Chronic pancreatitis is a rare childhood illness, most often presenting with nausea, vomiting, and recurrent abdominal pain. Obstructive jaundice secondary to biliary stricture is an uncommon manifestation of childhood pancreatitis, with only 11 patients previously described in the surgical literature. We report our experience with two additional children with jaundice secondary to pancreatitis and review the literature on this problem. Laboratory tests are often of little diagnostic value, and a high index of suspicion is essential for correct diagnosis. Endoscopic retrograde cholangiopancreatography is emerging as an extremely useful diagnostic study in these patients. The surgical management of this uncommon pediatric illness remains controversial.

Adolescent↗

PubMed1987

Long-term management of chronic constipation in children.

A retrospective clinical study was conducted to determine the success of a strict regimen employing the prolonged use of daily enemas in 203 children with chronic constipation. This study confirmed that the use of long-term daily enemas did eliminate constipation as well as the primary complaint of fecal soiling. The majority of children treated had an excellent to good result (85.8%) over an extended period of time. Patients with a past medical history of imperforate anus or Hirschsprung's disease required longer treatment periods (32.6 and 20.1 months, respectively) than children with other medical problems (rectal prolapse, rectal stricture, malrotation, spina bifida, mental retardation, psychological; 13 months) or patients with functional constipation (5.9 months).

Adolescent↗

PubMed1987

The practice of pediatric surgery in a medical school environment: is there a conflict between private practice and academic pursuits?

An 11-year review of the clinical practice and the academic activity of the Section of Pediatric Surgery at the University of Michigan was carried out. This was done in an attempt to determine whether or not increased clinical practice in a medical school environment would have a detrimental effect on academic productivity. Clinical activity was evaluated by analyzing the number of patients seen, the number of operations, patient days, admissions, and revenue generated. Academic activity was analyzed by measuring the number of hours of formal lectures and conferences, research space and personnel, the number of completed and active projects, grant support, and the number of publications. During this 11-year period, the number of operations performed increased from 525 per year to over 1,350, the number of office visits increased from 11 per week to 60 to 65, and the gross revenue increased six-fold. At the same time, the number of formal lectures and conferences given increased from 50 to 267 hours per year, the research space increased from 200 to 1,612 square feet, the research budget increased from $20,000 to $120,000 per year, grant support increased from 0 to $62,000 per year, and the number of publications increased from five to 17 per full-time equivalent (FTE) per year. In fact, this review indicates that during the time that clinical practice and revenue generation increased, so did academic productivity in the form of manuscript writing, project completion, and grant acquisition.(ABSTRACT TRUNCATED AT 250 WORDS)

Academic Medical Centers↗

PubMed1987

Physiologic assessment of the four commonly performed endorectal pullthroughs.

The popularity of the endorectal pullthrough for the treatment of benign mucosal diseases of the rectum has created a controversy regarding the need for a reservoir. The four currently advocated procedures, the straight endorectal anastomosis, the J pouch, the S pouch, and the lateral isoperistaltic ileal reservoir were evaluated in a puppy model with four animals in each experimental group. Measurement of rectal capacitance showed that all groups achieved 80-85% of control values at 6 months after surgery. Intestinal transit time decreased by one-half in all groups. Stool consistency, stool culture, water, and electrolyte absorption did not show any statistical superiority of one group over another. Stool frequency varied widely at 6 months; 10 stools per 8-hour period were counted in the lateral reservoir group versus 25 with the J pouches, and 16 with the straight and S groups. Stool frequency did not correlate with transit time, stool consistency, or rectal capacitance. Barium enemas showed that straight pullthroughs more closely resembled the measurements of the normal animal's endorectal canal. Based on these studies, there appears to be no advantage to adding a reservoir to the endorectal pullthrough.

Anal Canal↗

PubMed1987

Experience with the straight endorectal pullthrough for the management of ulcerative colitis and familial polyposis in children and adults.

The first significant experience with the straight endorectal pullthrough for the management of ulcerative colitis was presented before the American Surgical Association in 1977 by Lester Martin. Since then the operation with or without modification has been used extensively. High stool frequencies in some series led to disenchantment with the straight anastomosis and to the development of various reservoir procedures to increase rectal capacity and thereby reduce frequency. As a result, no large series of straight pullthroughs is available for comparison with the reservoir modifications. Between September 1977 and September 1986, 72 children and adults, 61 with ulcerative colitis and 11 with familial polyposis, underwent endorectal pullthrough (ERPT) and straight ileoanal anastomosis under the overall direction of a single surgeon (AGC). Sixty patients have undergone ileostomy closure and form the basis of this study. Mean age at operation was 22.7 years (range 4-48 yr), and duration of active disease averaged 6 years. One-half of the patients underwent total abdominal colectomy with ERPT as a primary procedure. There were 11 cases of adhesive bowel obstruction following ERPT, and in six patients in the series permanent revision to a Brooke ileostomy was required. One patient died of hepatic failure in the late postoperative period. Follow-up has ranged from 3 months to 9 years. Mean stool frequency for the group as a whole at 3, 6, 12, 24, and 36 months was 11.8, 11.2, 9.6, 9.0, and 8.3 per 24 hours, respectively. Daytime continence was achieved in all patients. Occasional nocturnal soiling occurred in 11.1% of patients at 1 year. Stool frequency and continence were also analyzed by age group above and below 18 years and above and below 30 years. There were no statistically significant differences between these groups. The authors conclude from this study that ERPT with straight ileoanal anastomosis remains an appropriate alternative for children and adults with ulcerative colitis or familial polyposis and compares favorably with the more complicated ERPT involving a reservoir.

Adenomatous Polyposis Coli↗

PubMed1986

Gastroesophageal reflux in children: is there a place for the upper gastrointestinal study?

Objective tests for gastroesophageal reflux in children have shown only fair correlation with clinical symptoms. Thirty-four children referred to the pediatric surgery service for evaluation of gastroesophageal reflux had both 24-hour pH probe monitoring and standardized upper gastrointestinal examinations. A total of 16 children (47%) had documented significant or pathologic gastroesophageal reflux, 11 on pH monitors and 9 on contrast examinations. There were 4 in whom both tests were positive. None of the pH monitoring criteria correlated with the radiographic studies. The patient population documented by contrast study did not differ from the general test-positive population by age or associated clinical findings. The 2 studies probably measure different aspects of significant gastroesophageal reflux, are confirmatory and complementary, and must be correlated with the clinical symptoms.

Adolescent↗

PubMed1986

Sonography of ruptured appendicitis.

Three girls and 4 boys with the final diagnosis of ruptured appendicitis underwent 19 sonographic studies, 5 before any therapy was instituted and 14 follow-up studies. Four abscesses identified before treatment and 2 seen postoperatively were ovoid, irregularly marginated, and contained low-amplitude echoes. Gastrointestinal ileus with gas-and fluid-filled loops of bowel made the studies technically difficult. Follow-up studies also showed fluid collections distant from the original abscesses. The complete resolution of the abscess was followed sonographically in 1 patient treated with antibiotics. Ultrasound can be useful in confirming or suggesting the diagnosis of ruptured appendicitis in the child with abdominal pain, but careful attention to detail is necessary in these technically difficult studies.

Abscess↗

PubMed1986

The radiographic appearance of the endorectal pull-through.

Children and young adults with ulcerative colitis and polyposis syndromes requiring colectomy are increasingly undergoing the endorectal pull-through procedure. We reviewed the contrast studies of the neorectum of 27 patients and the abdominal radiographs in 26 patients after the endorectal pull-through operation. Normal features included smooth mucosa with loss of the small bowel features, dilatation of the neo-rectum on consecutive examinations, and an enlarged presacral space. The normal appearance before closure of the ileostomy varied depending upon the amount of distension of the pull-through segment; redundant ileum within the rectal muscle sleeve was seen in the two patients. Abnormalities included rectovaginal fistulas, sinus tracts, focal strictures requiring dilatation, complete obstruction, mucosal irregularities, and generalized narrowing with lack of distensibility. These abnormalities are attributable to inflammation and were associated with a poor clinical outcome. A contrast examination of the pull-through segment is useful to exclude the presence of serious inflammatory change before ileostomy closure or in the patient with excessive diarrhea or obstruction.

Adolescent↗

PubMed1986

The use of pericardium for the management of recurrent tracheoesophageal fistula.

Correction of congenital esophageal atresia and tracheoesophageal fistula (TEF) with either a primary or staged repair may result in recurrence of the TEF, most often at the site of esophageal anastomosis. Definitive operative repair of a recurrent TEF involves isolation and resection of the fistula with closure of the tracheal and esophageal defects. A technique is described, whereby mobilization of a vascularized pedicle of pericardium allows further enhancement of the standard repair of a recurrent TEF. The vascularized pedicle of pericardium serves to isolate the tracheal and esophageal suture lines from each other, as well as aid in sealing leaks at either or both suture lines. This may dramatically reduce the incidence of second recurrences and lower the overall operative mortality, reportedly as high as 59%.

Humans↗

PubMed1986

Diagnosis and management of congenital cystic disease of the lung in children.

Pulmonary sequestration, congenital adenomatoid malformation (CAM), congenital lobar overinflation (CLO), and bronchogenic cysts are four congenital lesions that may present as abnormal cystic areas within the pleural cavity in early life. They share similar clinical and embryologic characteristics, are frequently difficult to diagnose, and all require surgical treatment. From December 1974 to January 1985, 22 patients were operated upon on the Pediatric Surgical Service for congenital cystic disease of the lung. There were eight females and 14 males, ranging in age from 1 day to 18 years; 12 were under 6 months of age, and 14 were under one year. There were 7 CAMs, 5 extralobar pulmonary sequestrations, 5 intralobar pulmonary sequestrations, 3 bronchogenic cysts, and 3 cystic lobes caused by CLO. One patient had bilateral pulmonary sequestrations, intralobar on one side and extralobar on the other, with both sharing a common systemic artery arising from the infradiaphragmatic aorta. All except two asymptomatic patients presented with either progressive respiratory distress or recurrent pulmonary infections, and had cystic changes noted on chest roentgenograms. The differentiation of these congenital lesions from resolvable inflammatory cysts is important. Diagnosis was aided by selective utilization of barium contrast studies, ultrasonography, computed tomography, and arteriography. Operation consisted of resection alone of the extralobar pulmonary sequestrations and bronchogenic cysts, and total lobectomy in CAM, intralobar sequestration, and CLO. One infant with CAM died 1 day postoperatively from bilateral hypoplastic lungs. The other 21 patients are alive and well with follow-up ranging from 1 month to 9 years, with a mean of 3.5 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1986

Extracorporeal membrane oxygenation (ECMO) in neonatal respiratory failure. 100 cases.

Extracorporeal membrane oxygenation (ECMO) was used in the treatment of 100 newborn infants with respiratory failure in three phases: Phase I (50 moribund patients to determine safety, efficacy, and risks); Phase II (30 high risk patients to compare ECMO to conventional ventilation); and Phase III (20 moderate to high risk patients, the current protocol). Seventy-two patients survived including 54% in Phase I, 90% in Phase II, and 90% in Phase III. The major complication was intracranial bleeding, which occurred in 89% of premature infants (less than 35 weeks) and 15% of full-term infants. Best survival results were in persistent fetal circulation (10, 10 survived), followed by congenital diaphragmatic hernia (9, 7 survived), meconium aspiration (44, 37 survived), respiratory distress syndrome (26, 13 survived), and sepsis (8, 3 survived). There were seven late deaths; in follow-up, 63% are normal or near normal, 17% had moderate to severe central nervous system dysfunction, and 8% had severe pulmonary dysfunction. ECMO is now used in several neonatal centers as the treatment of choice for full-term infants with respiratory failure that is unresponsive to conventional management. The success of this technique establishes prolonged extracorporeal circulation as a definitive means of treatment in reversible vital organ failure.

Catheterization↗

PubMed1986

Fifty years' experience with esophageal atresia and tracheoesophageal fistula. Beginning with Cameron Haight's first operation in 1935.

Four hundred twenty-six patients with esophageal atresia with or without tracheoesophageal fistula have been primarily cared for at the University of Michigan Medical Center since Cameron Haight's initial experience with this entity. Over the period of observation, the incidence of new cases as well as the number of associated anomalies has remained constant. The long-term survival of these patients has steadily improved over the past half-century from 36% in the pre-1950 era to 84% during the most recent 20 years. Conversely, operative mortality has shown a progressive decline from 56% early in the authors' series to 6.9% more recently, despite a steady increase in the proportion of high-risk neonates seen at the University of Michigan Medical Center during this time span. In the last 9 years, there have been no postoperative deaths in group A or B risk infants (36 patients), while the rate has been 18.2% in group C risk babies (27 patients); almost all of these deaths were due to severe associated anomalies. During the last 10 years, the authors have changed their technique of anastomosis from a two- to a one-layer method while still advocating a primary repair via an extrapleural approach. Although this change has resulted in a modest increase in the rate of anastomotic leak (17% vs. 6.2%, p less than 0.03), the leaks have been small and asymptomatic because of the extrapleural approach and, as a result, have been managed conservatively without any untoward sequelae. Conversely, there has been a significant decrease in the rate of stricture formation with the one-layer anastomosis (4.3% vs. 23.3%, p less than 0.002). While this may in part be explained by the change in anastomotic technique, it is felt that the more aggressive diagnosis and surgical management of gastroesophageal reflux (seen in 37.9% of our recent group) have contributed greatly to this decrease. The steady improvement in survival over this 50-year period, in spite of the increasing number of high-risk infants, is attributable to major improvements in neonatal care before, during, and after operation.

Esophageal Atresia↗

PubMed1986

Postappendectomy fluid collections in children: incidence, nature, and evolution evaluated using US.

At the authors' medical center, most patients with postappendectomy fluid collections are treated conservatively. Thirty-two (15%) of 216 children underwent postoperative sonography following appendectomies. In ten patients (31%), a total of 16 fluid collections were found on the initial postoperative sonogram. In the seven patients (70%) whose fluid collections were confined to the pelvis, the condition was treated conservatively and it resolved in 2-9 weeks. In three patients, fluid collections required surgical drainage and proved to be abscesses. In two of the three patients, abscesses were multiple and widely distributed in the abdomen, and the patients were clinically ill. The authors conclude that clinically symptomatic fluid collections develop postoperatively in approximately 5% of children who have undergone appendectomy for acute appendicitis and that the size and course of the fluid collection can be objectively monitored using sonography. Such fluid collections confined to the pelvis ultimately resolve with conservative, nonoperative therapy, although resolution may take up to 2 months.

Abdomen↗