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B C Sheppard

Publications and source records attributed to B C Sheppard.

At least 19 recordsLinked to original sources
PubMed2005

Ten-year trend in the national volume of bile duct injuries requiring operative repair.

BACKGROUND: The objectives of this study were to determine the national proportions and mortality rate for bile duct injuries resulting from laparoscopic cholecystectomy (LC) that required operative reconstruction for repair over a 10-year period and to investigate the major factors associated with the mortality rate in this group of patients. METHODS: Using the Nationwide Inpatient Sample (NIS) of >7 million patient records per year, we extracted and analyzed data for LC during the years 1990-2000. Procedures that involved biliary reconstructions performed as part of another primary procedure were excluded. Using the Statistical Package for the Social Sciences (SPSS), we used procedure-specific codes that enabled us to calculate national estimates for LC for the time period under review. We then calculated biliary reconstruction procedures that occurred after LC for this cohort of patients. Finally, we analyzed in-hospital mortality, as well as the patient, institutional, and outcome characteristics associated with biliary reconstructions. RESULTS: The percentage of cholecystectomies performed laparoscopically has increased over the years for which data are available (from 52% in 1991 to 75% in 2000). Despite this increase, the mortality rate for this group of patients has remained consistently low over the study period (mean, 0.45%; range 0.33-0.58%). Within this group of patients, the average rate of bile duct injuries requiring operative repair was 0.15% for the years under study. The reconstruction rates ranged from 0.25% in 1992 to 0.09% in 1999. For 2000, the most recent year for which data are available, biliary reconstruction was performed in 0.10% of all patients who underwent LC. The average mortality rate for patients undergoing biliary reconstruction for the years 1991 to 2000 was 4.5%. After multivariate analysis, age, African American ethnicity, type of admission, source of admission, and hospital location, and teaching status were all found to correlate significantly with death after-biliary reconstruction. CONCLUSIONS: These data show an increase in the percentage of cholecystectomies performed laparoscopically over the years under study and an associated low mortality rate. In contrast, although the number of bile duct injuries appears to be decreasing, these procedures continue to be associated with a significant mortality rate.

Adult↗
PubMed2003

Prevention of percutaneous endoscopic gastrostomy stoma metastases in patients with active oropharyngeal malignancy.

The implantation of metastasis of oropharyngeal or esophageal cancer to percutaneous endoscopic gastrostomy (PEG) stomata is considered an uncommon complication, but it is being recognized with increasing frequency. The incidence of this complication is not known. Multiple theories of metastatic spread have been proposed. We describe a case following retrograde endoscopy via a PEG stoma site. A National Library of Medicine literature search was performed, and case reports and bibliographies were reviewed. We estimate the incidence of this complication as 1% minimum. Direct seeding of the site is the only reasonable hypothesis to explain this phenomenon. Health care providers need to be educated about this problem. Although there is no direct evidence that metastases are spread by direct contact, we believe that transgression of the active primary tumor during gastrostomy tube placement should be avoided. Laparoscopic gastrostomy tube placement provides a safe, effective, and minimally invasive method of enteral access, which avoids transgression of the primary tumor site, and may prevent stomal metastases in patients with active aerodigestive tract malignancies who require gastrostomy.

Carcinoma, Squamous Cell↗
PubMed2003

Transition from open to laparoscopic adrenalectomy: the need for advanced training.

BACKGROUND: We sought to determine the learning curve for laparoscopic adrenalectomy (LA), current use of the procedure, and if indications for adrenalectomy had changed in the past decade. METHODS: A retrospective chart review was performed for all adrenalectomies after 1990. Practicing community surgeons in Oregon were mailed a questionnaire. RESULTS: Seventy-five LAs were performed at the Oregon Health and Sciences University and Portland VA Medical Center. Average operating room (OR) time was 161 min and average estimated blood loss (EBL) was 84 ml. There were four complications and two conversions. Comparing the first 20 to the last 20 patients, OR times were 154 vs 159 min (not significant), and EBL was 102 vs 47 ml ( p < 0.05). There were two vs one complications ( p > 0.05) and one conversion each. Most residents completed less than two procedures during training, and community surgeons performed none during training. Of 17 currently performing LA, 14 had postresidency training. Open technique was used more often for hormonal ablation and malignancy. CONCLUSION: Operative time and complications do not decrease with experience, but EBL does. Few, if any, residents acquire enough experience to perform LA in practice. The procedure is performed laparoscopically more often for benign disease.

Adrenal Gland Neoplasms↗
PubMed2003

The laparoscopic sponge.

PURPOSE: Hemorrhage and spillage of enteric contents during laparoscopic surgery can be problematic and obscure the operative field. Although the suction device can often clear the field, we have found that use of a sponge is often more efficient and effective. MATERIAL AND METHODS: An unrolled 4 x 4 sponge can be introduced down a 10-mm port without difficulty. The addition of a suture tied to one corner of the sponge allows easy retrieval of the sponge and eliminates the possibility of leaving the sponge in the abdomen. CONCLUSIONS: The laparoscopic sponge is simply constructed and is easily introduced and retrieved through a trocar. It can be used to deal with a troublesome hemorrhage, either to put on direct pressure or to absorb blood. It can also be used as a blunt retractor and dissector. With the addition of the suture tail, it is quickly retrieved and cannot be forgotten within the abdomen.

Blood Loss, Surgical↗
PubMed2001

Use of the radial forearm free tissue flap to treat persistent stricture after esophagogastrectomy.

BACKGROUND: Persistent stricturing or anastomotic leakage at the cervical esophagogastric anastomosis can be a troublesome complication of gastric pull-up procedures. When the stricture is the result of ischemia of the stomach, the strictures are long and often not responsive to dilatation and require large operations such as jejunal interposition or replacement with colonic pull-up. In this report we describe the use of a radial forearm flap to patch strictures. METHODS: The radial forearm flap is a fascia cutaneous flap taken from the forearm and based on the radial artery and its venae comitantes. The advantages of this flap are that it is thin and pliable, conforms easily, has excellent reliability due to the size of the feeding vessels, and has a relatively long pedicle. The vascular anastomosis can be made to several arteries and veins within the neck. The epithelial component can be made in sizes up to 10 by 20 cm. RESULTS: We have used the radial forearm flap to patch strictures in 6 patients with persistent complex strictures in the cervical region after esophagectomy. Results were excellent in 4 patients (able to eat liquids and solids without problems) and good in 1 patient (liquids okay, some problem with solids), and 1 patient died postoperatively. Follow-up is 4 months to 7 years. CONCLUSIONS: The radial forearm flap is an excellent option for handling persistent stricture after esophagogastrectomy. In many instances, this flap can be used in lieu of a jejunal interposition flap and obviates a laparotomy to harvest jejunum. The flap fits easily into the neck and conforms to the space.

Adult↗
PubMed2001

Does neoadjuvant chemoradiation downstage esophageal carcinoma?

BACKGROUND: Neoadjuvant chemoradiotherapy is administered to patients with esophageal carcinoma with the belief that this will both downstage the tumor and improve survival. Endoscopic ultrasound (EUS) is currently the most accurate method of staging esophageal cancer for tumor (T) and lymph node (N) status. Because both EUS and neoadjuvant therapy for esophageal carcinoma are relatively new, there are few data examining the relationship between EUS stage and histological stage (the stage after resection) in patients receiving neoadjuvant therapy. METHODS: To determine the effect of neoadjuvant chemoradiotherapy on T and N stage as determined by EUS, we retrospectively compared two groups of patients with esophageal cancer staged by EUS. One group (33 patients) underwent neoadjuvant therapy (Walsh protocol: 5-fluorouracil, cisplatin, and 4000 rads of external beam radiation) followed by resection. The second group (22 patients), a control group, underwent resection without neoadjuvant therapy. We then compared histological stage to determine if there was a downstaging in the patients receiving neoadjuvant therapy. Survival was evaluated as well. RESULTS: EUS accurately predicted histologic stage. In the control group EUS overestimated T stage in 3 of 22 (13%), underestimated N stage in 2 of 22 (9%), and overestimated N stage in 2 of 22 (9%) of patients. Preoperative radiochemotherapy downstaged (preoperative EUS stage versus pathologic specimen) 12 of 33 (36%) of patients whereas only 1 of 22 (5%) of patients in the control group was downstaged. Complete response (no tumor found in the surgical specimen) was observed in 5 of 33 (15%) of patients receiving radiochemotherapy. Survival was prolonged significantly in patients receiving radiochemotherapy: 20.6 months versus 9.6 months for those (stage II or III) patients not receiving radiochemotherapy (P <0.01). Operative time, operative blood loss, and length of stay were not significantly different between groups. Perioperative mortality was higher in the radiochemotherapy group (13%) compared with the no radiochemotherapy group (5%) but did not achieve statistical significance. CONCLUSIONS: EUS accurately stages esophageal carcinoma. Neoadjuvant radiochemotherapy downstages esophageal carcinoma for T and N status. In our nonrandomized study, neoadjuvant therapy conferred a significant survival advantage. Operative risk appears to be increased in patients receiving neoadjuvant radiochemotherapy prior to esophagectomy.

Adult↗
PubMed2001

Anomalous left adrenal venous drainage directly into the inferior vena cava.

Primary hyperaldosteronism is a potential cause of hypertension. Unilateral adrenal adenoma and bilateral adrenal cortical hyperplasia are the most common causes of primary hyperaldosteronism. Adrenal venous sampling is employed as the gold standard test to differentiate between these two different causes when the results of other studies in the work-up protocol are non-diagnostic or ambiguous. Adrenal venous sampling can be a challenging procedure, especially in the presence of anomalous venous drainage patterns. Knowledge of normal adrenal venous anatomy, as well as possible variants, is therefore important to ensure a successful procedure. The authors describe an unusual variant of left adrenal venous drainage directly into the IVC.

Adrenal Gland Diseases↗
PubMed2000

Laparoscopic heller myotomy and anterior fundoplication for achalasia results in a high degree of patient satisfaction.

HYPOTHESIS: Laparoscopic Heller myotomy with anterior fundoplication will alleviate the symptoms of achalasia and result in excellent patient satisfaction. DESIGN: Retrospective study of consecutive patients who underwent laparoscopic Heller myotomy with anterior fundoplication for achalasia between October 1995 and July 1999. A telephone survey assessed symptoms and satisfaction. Patients were asked to quantitate their symptoms on a scale of 0 to 3 (0 = none; 1, mild; 2, moderate; and 3, severe). SETTING: University referral center. PATIENTS: Twenty-four patients who underwent laparoscopic Heller myotomy with anterior fundoplication for achalasia. MAIN OUTCOME MEASURES: Postoperative symptoms and satisfaction. RESULTS: Twenty-one patients (88%) were successfully contacted. Mean follow-up was 16.5 months. The laparoscopic approach was successful in all but 3(88%). The mean dysphagia score was 2.81 preoperatively and 0.81 postoperatively (P<.000). The mean chest pain score was 1. 57 preoperatively and 0.86 postoperatively (P<.015). The mean supine regurgitation score was 2.10 preoperatively and 0.57 postoperatively (P<.000). The mean upright regurgitation score was 1.57 preoperatively and 0.52 postoperatively (P<.000). The mean heartburn score was 1.57 preoperatively and 0.57 postoperatively (P<.000). Postoperatively, 18 (86%) of 21 patients could swallow bread without difficulty and 17 (89%) of 19 patients could eat meat without difficulty (2 were excluded as they were vegetarians). Twenty (95%) of 21 patients reported improvement after the operation. CONCLUSIONS: Laparoscopic Heller myotomy with anterior fundoplication significantly relieves the symptoms of achalasia without causing the symptoms of gastroesophageal reflux disease. This procedure results in excellent overall patient satisfaction.

Adolescent↗
PubMed1999

Effects of paclitaxel on the growth of normal, polyposis, and cancerous human colonic epithelial cells.

BACKGROUND: The specific paclitaxel dose or time course in the treatment of colon carcinoma without the disruption of normal colonic cell proliferation is currently not known. The aim of this study was to determine the effects of paclitaxel on the growth of human colonic epithelial cells using cultures of normal, polyposis, and cancerous cells. METHODS: Normal, polyposis, and cancerous human colonic cells (Caco-2, T-84, and LoVo cell lines) were cultured, then treated with paclitaxel (10(-9)-10(-5) M) for 0-7 days.[AU: Please verify all dosages throughout.] Cell proliferation was assayed using either a Coulter-Counter or MTT-growth assay. Immunofluorescence and Western immunoblotting measured P-glycoprotein. RESULTS: Low paclitaxel doses (1 x 10(-9)-10(-8) M) were more effective than higher paclitaxel doses (>1 x 10(-8) M) in the growth inhibition of polyposis, Caco-2, and LoVo cancer (but not T-84) cell lines. Low paclitaxel doses had little effect on normal colonic cell growth over 7 days. Higher paclitaxel doses (>1 x 10(-8)-10(-5) M) produced a dose-dependent inhibitory effect on the growth of normal human colonic epithelial cells over 7 days but had no effect on the growth of polyposis, Caco-2, and LoVo cells over 3-7 days of treatment. Immunofluorescence and Western immunoblotting of cultures showed that 1 x 10(-6) M paclitaxel increased P-glycoprotein expression in Caco-2 and LoVo cells. There was no effect of paclitaxel on P-glycoprotein expression in T-84 cancer cells, which were found to have high endogenous basal levels of P-glycoprotein. P-glycoprotein expression in Caco-2 cells was found on plasma membranes and in perinuclear areas. CONCLUSIONS: Lower paclitaxel doses are more effective over time for the growth inhibition of polyposis and cancerous colonic cells, with minimal effects on the growth of normal colonic epithelial cells. Increased P-glycoprotein expression appears to be correlated with paclitaxel resistance in polyposis and cancerous colonic cells.

ATP Binding Cassette Transporter, Subfamily B, Mem↗
PubMed1999

Surgical options in the management of groin hernias.

Inguinal and femoral hernias are the most common conditions for which primary care physicians refer patients for surgical management. Hernias usually present as swelling accompanied by pain or a dragging sensation in the groin. Most hernias can be diagnosed based on the history and clinical examination, but ultrasonography may be useful in differentiating a hernia from other causes of groin swelling. Surgical repair is usually advised because of the danger of incarceration and strangulation, particularly with femoral hernias. Three major types of open repair are currently used, and laparoscopic techniques are also employed. The choice of technique depends on several factors, including the type of hernia, anesthetic considerations, cost, period of postoperative disability and the surgeon's expertise. Following initial herniorrhaphy, complication and recurrence rates are generally low. Laparoscopic techniques make it possible for patients to return to normal activities more quickly, but they are more costly than open procedures. In addition, they require general anesthesia, and the long-term hernia recurrence rate with these procedures is unknown.

Diagnosis, Differential↗
PubMed1999

Surgical options in the management of groin hernias.

Inguinal and femoral hernias are the most common conditions for which primary care physicians refer patients for surgical management. Hernias usually present as swelling accompanied by pain or a dragging sensation in the groin. Most hernias can be diagnosed based on the history and clinical examination, but ultrasonography may be useful in differentiating a hernia from other causes of groin swelling. Surgical repair is usually advised because of the danger of incarceration and strangulation, particularly with femoral hernias. Three major types of open repair are currently used, and laparoscopic techniques are also employed. The choice of technique depends on several factors, including the type of hernia, anesthetic considerations, cost, period of postoperative disability and the surgeon's expertise. Following initial herniorrhaphy, complication and recurrence rates are generally low. Laparoscopic techniques make it possible for patients to return to normal activities more quickly, but they are more costly than open procedures. In addition, they require general anesthesia, and the long-term hernia recurrence rate with these procedures is unknown.

Diagnosis, Differential↗
PubMed1999

Transition from open to laparoscopic fundoplication: the learning curve.

BACKGROUND: Two of us (B.C.S. and C.W.D.) began performing laparoscopic fundoplication in 1992. We have always designated the resident as the operating surgeon. OBJECTIVE: To determine the time necessary for both experienced surgeons and residents to become proficient in laparoscopic fundoplication. DESIGN: The medical records of 241 consecutive patients undergoing laparoscopic fundoplication were reviewed. This period started with the implementation of the procedure in January 1992 and ended in March 1998. For 3 consecutive years, residents were given a questionnaire regarding their confidence in performing laparoscopic fundoplication. RESULTS: Laparoscopic fundoplication was attempted in 241 patients and completed in 203 patients (84%). Comparing the first 25 attempted laparoscopic fundoplications with the second 25, there were 14 conversions (56%) vs 4 conversions (16%) (P<.01). Average operative times decreased from 236 to 199 minutes (P<.05), and the intraoperative complication rates were 5 (20%) and 1 (4%), respectively. Subsequently, the conversion rate stabilized at 2%. The operative time continued to decline to an average of 99 minutes for the last 25 laparoscopies. Senior residents and recent graduates returning the questionnaire performed an average of 112 laparoscopic procedures, including 15.7 laparoscopic fundoplications. They felt comfortable with the procedure after performing an average of 10.6 operations. CONCLUSIONS: The learning curve is very steep for the first 25 laparoscopic fundoplications for experienced surgeons. However, improvements, as judged by decreases in operative time, conversion rate, and intraoperative complications, continue to occur after 100 cases. Under supervision, residents can become comfortable with this procedure after about 10 to 15 procedures.

Clinical Competence↗
PubMed1999

Identification of a functional Ca2+-sensing receptor in normal human gastric mucous epithelial cells.

The purpose of the present study was to determine whether human gastric mucous epithelial cells express a functional Ca2+-sensing receptor (CaR). Human gastric mucous epithelial cells were isolated from surgical tissues and cultured on glass coverslips, plastic dishes, or porous membrane filters. Cell growth was assessed by the MTT assay, CaR localization was detected by immunohistochemistry and confocal microscopy, CaR protein expression was assessed by Western immunoblotting, and intracellular Ca2+ concentration ([Ca2+]i) was determined by fura 2 spectrofluorometry. In paraffin sections of whole stomach, we found strong CaR immunohistochemical staining at the basolateral membrane, with weak CaR-staining at the apical membrane in mucous epithelial cells. Confocal microscopy of human gastric mucous epithelial cell cultures showed abundant CaR immunofluorescence at the basolateral membrane and little to no CaR immunoreactivity at the apical membrane. Western immunoblot detection of CaR protein in cell culture lysates showed two significant immunoreactive bands of 140 and 120 kDa. Addition of extracellular Ca2+ to preconfluent cultures of human gastric mucous epithelial cells produced a significant proliferative response. Changes in [Ca2+]i were also observed in response to graded doses of extracellular Ca2+ and Gd3+. The phospholipase C inhibitor U-73122 specifically inhibited Gd3+-induced changes in [Ca2+]i in the gastric mucous epithelial cell cultures. In conclusion, we have identified the localization of a functional CaR in human gastric mucous epithelial cells.

Blotting, Western↗
PubMed1998

Comparison of outcomes of open versus laparoscopic Nissen fundoplication performed in a single practice.

BACKGROUND: We reviewed Nissen fundoplications performed in a single practice from January 1989 to March 1997, encompassing our transition from open to laparoscopic procedures. Because all operations were done by two surgeons in the same two hospitals, the study is well controlled for comparisons. METHODS: Records of 271 consecutive patients were reviewed. RESULTS: From 1989 to 1992 all patients underwent open fundoplication (n = 78). Thereafter, with increasing frequency, laparoscopic fundoplication was performed. The laparoscopic group was slightly younger (48 +/- 14 years) than the open group (54 +/- 13 years), but gender distribution and body mass index (BMI) did not differ. Mean operating time for laparoscopic cases was 163 +/- 58 minutes compared with 148 +/- 59 minutes for open cases (NS). Intraoperative complication rate was 8% for both groups. Length of hospitalization was shorter for patients undergoing laparoscopic surgery (2.4 days versus 7.2 for open procedures, P <0.05). In follow-up, 82% of the open Nissen group were asymptomatic compared with 84% of the laparoscopic Nissen group. The same proportion of patients required reoperation for dysphagia (3% for each group). Of patients who had the open procedure, 21% had wound complications. None of those treated laparoscopically had long-term morbidity from trocar insertion sites. CONCLUSION: Equal effectiveness in treating reflux combined with shorter hospitalization and absence of wound complications makes the laparoscopic approach the preferred method for performing fundoplication.

Adult↗
PubMed1998

The utility of polyglycolic acid mesh for abdominal access in patients with necrotizing pancreatitis.

BACKGROUND: Necrotizing pancreatitis is a poorly understood process that has been treated by a variety of surgical approaches. Despite advances in operative interventions and critical care, this disease often requires prolonged resource allocation and continues to cause substantial morbidity, with mortality rates ranging from 11% to 40%. We report on our recent series of patients with necrotizing pancreatitis and our experience with the use of an absorbable mesh in a subset of these patients to facilitate their surgical care. STUDY DESIGN: From 1985 to 1994, 40 patients with culture-proved necrotizing pancreatitis underwent operative debridement and drainage. Surgical outcomes were compared among patients who underwent a single debridement and drainage, those requiring multiple procedures, and those having placement of polyglycolic acid mesh. RESULTS: The overall hospital mortality rate was 30%. The mean length of hospital stay was 35 days. The rate of infected pancreatic necrosis was 60%, with a mortality rate of 45% in patients having infected pancreatic tissue at surgery. Patients without infected pancreatic tissue at surgery had a mortality rate of 6% (p = 0.03). Eleven patients requiring multiple operations had placement of absorbable polyglycolic acid mesh. Clinic followup was possible in five of six survivors who underwent mesh closure. Abdominal-wall hernias developed in two patients and were repaired electively, and three patients had spontaneous closure by granulation without abdominal-wall hernias. The average number of operations for debridement and drainage was 2.5 (range, 1-15). Patients with limited pancreatic necrosis required a single operative debridement and drainage, and this was associated with improved outcomes. CONCLUSIONS: Necrotizing pancreatitis remains an important challenge in surgical care. It requires prolonged hospitalization, costly resources, and causes substantial morbidity and mortality. Our patients with infected pancreatic necrosis or clinical deterioration underwent open staged necrosectomy and debridement. Those patients requiring repeat laparotomy often had placement of polyglycolic acid mesh. This provided open drainage of the abdominal cavity and simplified further care by allowing easy abdominal access for repeat drainage procedures, often performed in the intensive care unit. These patients had a high rate of fistula formation, which may be decreased by changes in wound care. Polyglycolic acid mesh is a useful adjunct in the surgical care of selected patients with necrotizing pancreatitis.

Abdominal Muscles↗