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Biomedical subjects

B R Taylor

Publications and source records attributed to B R Taylor.

At least 55 records · Page 3Linked to original sources
PubMed1987

Examination of patient selection and outcome for hepatic resection for metastatic disease.

Hepatic resection for metastatic disease is now an accepted therapeutic option in a selected group of patients. A series of 56 patients undergoing hepatic resection at a single institution from 1974 to 1985 are presented. Resection was carried out in 27 women and 29 men who ranged in age from 23 to 87 years (a mean of 56 years). The site of primary disease was: colorectal in 41, adrenal gland in two and other sites in 13. Of the 56 hepatectomies, 21 were done for synchronous secondary disease discovered before or at operation for the primary disease. Metachronous lesions were found in 35 patients, from two months to 17 years (a mean of 34 months) after excision of the primary tumor. Estimated five year survival rates using the Kaplan-Meier method was 25 per cent in the patients with colorectal primaries and 35 per cent in the entire group. No difference was demonstrated between synchronous and metachronous resections. Patients with multiple hepatic lesions did much poorer than those with solitary tumors. Patients with metastatic tumor consisting of one large lesion with surrounding satellite nodule or nodules had an expected survival time resembling that for those with true solitary metastases and were included in that group. No difference in survival time was observed in patients with carcinoma of the colon and rectum who had involvement of regional nodes at the time of the primary resection, as compared with patients with negative nodes. Hepatic resection for a secondary malignant growth can be performed safely with a real chance for cure in selected instances. We continue to recommend an aggressive approach to hepatic metastases, especially those of a colorectal origin.

Adenocarcinoma↗
PubMed1986

Effects of peritoneovenous shunting on body composition.

The effect of peritoneovenous shunting on body composition has been studied in 7 cirrhotic patients undergoing a successful shunt and 3 patients in whom the shunt was unsuccessful. In the 7 patients with functioning shunts, their weight had decreased by a mean of 9 kg (p less than 0.001) by 6 wk after initial diuresis, natriuresis, and kaliuresis, and was associated with a decrease in total body potassium (TBK) but not total body nitrogen (TBN). This resulted in a significant decrease in the TBK/TBN ratio from 2.12 +/- 0.74 to 1.66 +/- 0.20 (p less than 0.01). By a mean of 14 mo, in these 7 patients there was a significant increase in mean TBN (from 1.54 +/- 0.10 to 1.84 +/- 0.10, p less than 0.005) associated with an improvement in the mean nitrogen index (from 0.74 +/- 0.04 to 0.88 +/- 0.04, p less than 0.005). These changes were associated with a significant increase in nonalcoholic calories, a nonsignificant increase in protein consumption, and a positive nitrogen balance. After the initial kaliuresis, mean potassium balance remained constantly positive (+22.7 +/- 3.4 mmol/day), serum aldosterone levels normalized, and TBK increased. In contrast, 3 patients with failed peritoneovenous shunting continued to lose weight significantly despite the presence of ascites; TBN and nitrogen index also decreased. In conclusion, body composition studies appear to have confirmed the clinical observation that cirrhotic patients with massive ascites have depleted body protein which is gradually repleted only after successful shunting. In this situation TBK, long used as a measure of lean body mass, is less satisfactory than TBN and nitrogen index. This improvement in body protein appears to be explained by an increased dietary intake associated with improved nitrogen balance, but these changes are not found in patients in whom the shunt failed.

Adult↗
PubMed1985

Further report of a prospective randomized trial comparing distal splenorenal shunt with end-to-side portacaval shunt. An analysis of encephalopathy, survival, and quality of life.

We electively compared the distal splenorenal ("selective") shunt with the end-to-side portacaval shunt in 80 prospectively randomized patients with variceal bleeding. Selective shunts required more operative time (3.9 vs. 2.8 h) and blood replacement (4.6 vs. 2.5 U) and postoperative mortality was slightly higher (5 of 38 selective vs. 0 of 40 portacaval). Postoperative complication rates were similar. After 65-mo mean follow-up, both shunts have protected well against late gastrointestinal bleeding (5 selective, 4 portacaval episodes). However, after selective shunts, spontaneous encephalopathy occurred less often (23% vs. 40% of patients), was severe in fewer patients (12% vs. 33%), and precipitated fewer hospital admissions (6 admissions in 4 selective patients vs. 26 admissions in 13 portacaval patients). Furthermore, selective shunt patients remained longer without functional disability (83% vs. 70% of postoperative patient months). Long-term survival was not significantly different in the two groups (5-yr survival: selective 51%, portacaval 56%).

Adult↗
PubMed1985

Periampullary tumors: which ones should be resected?

Resection was carried out in 118 patients for periampullary lesions. Ninety-eight of these were adenocarcinomas and were treated by the Whipple operation, total pancreatectomy, or local resection (87 patients, 7 patients, and 4 patients, respectively). Diagnosis of pancreatic head carcinoma before resection was falsely positive in 27 percent of the patients. Mortality for radical resection was 4 percent. Five year survival for ampullary carcinoma was 32 percent, and for pancreatic head carcinoma it was 7 percent. Resection of all periampullary tumors is recommended, with the Whipple operation being the standard in most cases.

Actuarial Analysis↗
PubMed1985

Carcinoma of the extrahepatic bile ducts: results of an aggressive surgical approach.

Ninety patients with adenocarcinoma of the extrahepatic bile ducts were treated between 1969 and 1984. Fifty-four tumors involved the upper third, 15 the middle third, and 21 the lower third of the common duct. Twenty-two patients had gallstones and five had inflammatory bowel disease. Forty-three patients had operations before definitive treatment; the diagnosis was made in only 18. Resection was accomplished in 30 patients (33%): 12 of 54 in the proximal third, six of 15 in the middle third, and 12 of 21 in the distal third. The mean survival in patients who underwent resection was 32 months (proximal third, 28 months; middle third, 32 months; lower third, 37 months). Surgical bypass was performed in 28 patients (mean survival 10 months) and intubation alone was performed in 24 patients (mean survival 8 months). Recurrent cholangitis occurred in 56% of intubated patients compared with 26% of patients treated without tubes. Radiation was used with resection and for palliation. Responses were observed, but the complication of radiation duodenitis has limited the dose. An aggressive approach to resection of bile duct tumors is possible with a low operative mortality rate and offers the best opportunity for cure as well as good palliation. Internal bypass is preferable to chronic intubation. The role of radiation therapy in this disease is still not clear.

Adenocarcinoma↗
PubMed1984

Management of patients with polyps containing malignancy removed by colonoscopic polypectomy.

The management of malignant colonic polyps removed colonoscopically has been a controversial subject. A continuing series is reported of 36 patients with 37 malignant polyps removed by colonoscopic polypectomy (CP) between 1976 and 1982. Fourteen polyps contained carcinoma in situ (CIS); 13 were treated by CP alone; one was treated by CP and colectomy. Nineteen polyps contained invasive carcinoma; 13 were treated by CP alone; six were treated by CP and colectomy. Four patients had sessile polyps resected piecemeal, in which accurate staging was impossible. Two were treated with CP alone, and two had CP plus colectomy. All patients were followed with yearly colonoscopy and/or barium enema. Follow-up has been six to 84 months (mean 36 months). Twenty-seven patients whose polyps were treated by CP alone have had no evidence of recurrent tumor at the polypectomy site. Of the nine patients undergoing colectomy, six had residual tumor at the polypectomy resection site. No patients had involved lymph nodes. Our current approach to this problem is based on the degree of invasion and the status of the resection margins. Polyps containing CIS can safely be treated with CP alone. Polyps with invasive carcinoma and clear resection margins should be treated with CP and either colectomy or frequent repeat colonoscopy. This decision is a clinical one and must involve input from both the clinician and the pathologist. Those polyps whose resection margins are involved or where piecemeal excision precludes accurate pathologic assessment should undergo colectomy.

Adenoma↗
PubMed1984

Diagnosis and management of hydatid disease of the liver. A 15-year North American experience.

Since 1967, 40 patients with hydatid disease of the liver have been treated at our hospital. Diagnosis was made using clinical criteria, serology, skin tests, and imaging techniques. Thirty-five patients were operated upon. In 18 patients the cyst was uncomplicated (Group I), and in 17 the cyst was infected or communicated with the biliary tract (Group II). Three forms of surgical treatment were used: A) cyst evacuation, scolicidal irrigation, and primary cyst closure, B) evacuation, irrigation, and external drainage, and C) complete or partial cyst resection. Mebendazole was used in six patients, four of whom were also treated surgically. In Group I, one of 11 patients (8%) treated by primary closure had complications, versus four of five patients (80%) treated with external drainage (p less than 0.001). Mean postoperative hospital stay for these two groups was 11.8 versus 20.8 days, respectively (p less than 0.001). Complication rates in Group II were higher, and were evenly distributed among treatments. Patients have been followed yearly, with a median follow-up of 5 years. Active hydatid disease has been found in three patients, who all had known residual disease at initial operation. The best treatment for an uncomplicated hydatid liver cyst is evacuation, scolicidal irrigation, and primary closure. External drainage is used for infected cysts or those communicating with the biliary tract, and excision for extrahepatic and peripheral, easily resectable cysts. Mebendazole is used for intraperitoneal spillage of cyst contents and in patients with inoperable disease.

Adult↗
PubMed1984

Nonsurgical treatment of common-bile-duct stones.

Exploration of the common bile duct, the traditional treatment for choledocholithiasis, can often be replaced by nonsurgical procedures. Since 1976, 147 patients have been treated nonsurgically with an overall success rate of 84%. Three groups are reported. In group 1, 80 patients had stone extraction under radiologic control through the T-tube tract alone. Stones were successfully removed from the common bile duct in 52 of 59 patients and from the intrahepatic ducts in 12 of 21 patients. The overall success rate of extraction through the T tube was 80%. Group 2 comprised 58 patients who underwent endoscopic sphincterotomy and stone extraction only with 86% success. The nine patients in group 3 required a combination of radiologic and endoscopic intervention. Six had stones "pushed" by the radiologist through a previously sphincterotomized ampulla of Vater and in two the radiologist introduced stone crushers transhepatically into the common duct to break up large stones to a size capable of passing through the sphincterotomy site (100% success). One elderly patient had a cholecystostomy under local anesthesia for suppurative cholecystitis, and subsequently multiple common-bile-duct stones were removed by the radiologist through the gallbladder and cystic duct and by the endoscopist through the endoscopic sphincterotomy site. All procedures were carried out under local anesthesia, and most required a hospital stay of 1 day or less. Complications were minimal and there were no deaths. T-tube extraction and endoscopic sphincterotomy are effective, relatively safe, nonsurgical procedures for the removal of common-duct stones.

Adult↗
PubMed1984

Results and hemodynamic changes after interposition mesocaval shunt.

Forty-seven patients have been treated by interposition mesocaval shunting for portal hypertension and variceal bleeding between December 1973 and March 1980. The average age was 55 years. The underlying diseases were alcoholic cirrhosis in 26 patients (56%), macronodular cirrhosis in 11 patients (23%), and other causes in 10 patients (21%). Thirty-five operations (75%) were performed on an emergency basis for patients who continued to bleed after failure of conservative management. In these patients, the early mortality rate was 43%. Overall survival, rebleeding, and postshunt encephalopathy rates are correlated with the preoperative Child's classification. These figures are similar to those reported for end-to-side portocaval shunts. The improvement in postshunt encephalopathy rates as reported by Drapanas is not borne out by our results. Postshunt angiography was performed in 31 patients and shunt patency was confirmed in 28 (90%). In 26 patients, selective studies to determine portal flow patterns were carried out, and in only three patients was there any evidence of hepatopedal flow. In each of these patients, some kinking of the shunt was noted. Mesocaval shunting is a reasonable alternative to end-to-side portocaval shunts and is associated with similar rates of patency, rebleeding, mortality, and late postoperative encephalopathy. A well-constructed, patent mesocaval shunt totally diverts portal flow.

Adult↗
PubMed1983

Formation of intrahepatic portosystemic shunts using a balloon dilatation catheter: preliminary clinical experience.

Six patients with advanced cirrhosis and portal hypertension had life-threatening upper gastrointestinal hemorrhage from esophageal varices. The varices were obliterated angiographically, using the transjugular approach, after which an intrahepatic portosystemic shunt was created in each case by inflating the balloon of a Grüntzig dilatation catheter in the needle tract between the portal and hepatic veins. All of the patients were expected to succumb quickly to their severe liver disease and massive variceal bleeding, but three of the six survived the initial hemorrhage, and two of these were discharged from hospital. There was an initial reduction of portal venous pressure of 10-15 mm Hg in all patients. All six shunts were patent angiographically 12 hr after the procedure. Two patients had venograms 5 days later and both shunts were patent. All six patients died within 6 months, but in three of the four postmortem examinations the shunts were easily identified and shown to be patent, the last of these 6 weeks after the procedure. These findings suggest that the technique could be of therapeutic value in the management of patients with portal hypertension.

Aged↗
PubMed1983

Hyponatremia and arginine vasopressin secretion in patients with refractory hepatic ascites undergoing peritoneovenous shunting.

Seven patients with persistent hyponatremia but normal or elevated serum arginine vasopressin levels and refractory ascites undergoing peritoneovenous shunting were studied in a Metabolic Unit on a 20 mEq sodium 1200 ml fluid-restricted diet to elucidate the mechanism of this response. The intravascular volume expansion after shunt implantation resulted in improvements in cardiac output, renal plasma flow and creatinine clearance (70.7 +/- 9.5 to 140.1 +/- 18.5 ml/min, p less than 0.005). There was an immediate diuresis (632 +/- 135 to 2450 +/- 323 ml/day, p less than 0.005) and natriuresis (3 +/- 1 to 25.9 +/- 10.6 mEq/24 h, p less than 0.05), and urine osmolality decreased significantly (622 +/- 91 to 251 +/- 76 mosmol/L, p less than 0.05) with a significant rise in serum sodium concentration by 72 hr (131 +/- 2 to 135 +/- 1.6 mEq/L, p less than 0.05) and serum osmolality. Serum arginine vasopressin levels remained elevated at 3.85 +/- 0.94 microU/ml, however, although a transient depression cannot be excluded. Subsequently, a small but significant decrease in serum arginine vasopressin levels to 3.04 +/- 0.65 microU/ml (p less than 0.05) was associated with a further rise in serum sodium levels above baseline values (138 +/- 1.4 mEq/L, p less than 0.01) and in serum osmolality. In conclusion, these results indicate that in this group of cirrhotic patients with refractory ascites, intrarenal factors, such as decreased delivery of filtrate to the distal nephron as well as elevated inappropriate levels of arginine vasopressin, are important in the pathogenesis of hyponatremia.

Aldosterone↗
PubMed1982

Hematogenous infection of peritoneovenous shunts after dental procedures.

In two patients who had peritoneovenous shunts inserted for the treatment of intractable ascites, the shunt became infected following dental procedures that were carried out without antibiotic prophylaxis. The organisms grown were alpha-hemolytic streptococcus in one patient, and alpha-hemolytic streptococcus and Klebsiella pneumoniae in the other. Alpha hemolytic streptococcus is commonly found in the oral cavity and has also been found, related to dental manipulations, in hematogenous infections at other sites. In both patients the infections were successfully managed by antibiotic treatment with removal of the infected shunt. Physicians caring for patients with peritoneovenous shunts should be aware of this potential complication; antibiotics should always be given prophylactically at the time of dental procedures.

Adult↗
PubMed1982

Intermittent percutaneous infusion into the hepatic artery of cytotoxic drugs for hepatic tumours.

Between June 1, 1976 and Apr. 30, 1981, 157 patients were treated for inoperable cancer of the liver by intermittent percutaneous infusion of chemotherapeutic agents into the hepatic artery. The majority of these patients had metastatic colorectal cancer. The regimen of chemotherapeutic infusion evolved during the study and is described. The survival of the total group of patients is analysed according to type of cancer, extent of disease, dosage and combination of drugs. This therapeutic modality appears to benefit patients with metastases from colorectal cancer confined to the liver. The complication rate for this procedure is relatively low. The results from this study suggest that intermittent percutaneous infusion of cytotoxic agents into the hepatic artery is worthwhile for selected patients and should be studied further in combination with other forms of therapy.

Adult↗
PubMed1982

Iatrogenic bile-duct strictures.

Management of iatrogenic stricture of the bile ducts is difficult and is associated with substantial morbidity and mortality. At the Toronto General Hospital, 61 patients with strictures following operative trauma underwent a total of 75 repairs. The overall success rate was 80%. End-to-end duct repair is preferred when feasible; 8 of the 61 patients were treated this way, with success in 7. In the majority of patients, however, extensive duct scarring and shortening preclude its use, necessitating Roux-en-Y hepaticojejunostomy, done in 53 cases. If the anastomosis is adequate, with good mucosal approximation, a stent is not essential and of 12 such operations, 10 were successful. Even when the mucosa-to-mucosa apposition is less than optimal, the use of a straight-tube stent or changeable U-tube stent may produce a satisfactory end result. Of 41 such operations, 31 were successful. Since iatrogenic bile-duct strictures lead to high morbidity and frequent recurrence despite seemingly adequate repair, continued emphasis should be placed on prevention of injury, especially during routine cholecystectomy. Experience, careful dissection, knowledge of anatomic variations and good judgement concerning the performance of a cholecystostomy in difficult situations, should all reduce this complication to a minimum.

Adolescent↗
PubMed1981

Mucocele of the appendix: pseudomyxoma peritonei and intracytoplasmic canaliculus-like structures.

A case of pseudomyxoma peritonei associated with mucocele of the appendix is reported. To date there is no general agreement as to whether this entity (pseudomyxoma) should be categorized as a malignant lesion. The presence of intracellular canaliculus-like structures adds support to those investigators who believe that pseudomyxoma peritonei reflects a form of malignant disease.

Appendix↗
PubMed1981

Renal and hemodynamic effects of the peritoneovenous shunt. II. Long-term effects.

The long-term renal and hemodynamic effects of the peritoneovenous shunt for intractable ascites were studied in 11 patients to elucidate the mechanism of its persistent beneficial effect. Sodium balance studies were performed in 7 patients. All had patent shunts and no clinically detectable ascites. On a 20-mEq sodium diet, the mean sodium excretion was 17.2 +/- 5.3 mEq/day which was increased over the preoperative mean of 2.4 +/- 0.4 (p < 0.025) on the same diet. There was a 100% increase in creatinine clearance over the preoperative level (p < 0.0005). The mean plasma renin activity and serum aldosterone levels were within normal limits in most patients, and the sodium excretion correlated inversely with the levels of each. During 100-mEq sodium challenge diet, the sodium excretion ranged from 4 to 130 mEq/day with a mean of 56.1 +/- 16.5 and with 6 of the 7 patients displaying sodium retention. On this diet the mean creatinine clearance was 104.3 +/- 6.4 ml/min, and the mean plasma renin activity and serum aldosterone levels had decreased physiologically with the higher sodium intake. Again the sodium excretion correlated inversely with the serum aldosterone on the 100-mEq sodium diet. In 8 patients, the portal pressure, as reflected by the wedge hepatic vein pressure, had decreased by a mean of 37% (p < 0.0005). But, despite this, 2 of the 8 patients had major variceal hemorrhages postoperatively. There was a significant inverse correlation between the increase in sodium excretion and the fall in portal pressure in 4 patients. Thus, sodium retention in cirrhosis is multifactorial with the reninaldosterone system and, possibly, portal hypertension per se both playing a role. Peritoneovenous shunting in carefully selected patients partially reverses the sodium retention and renders patients more manageable over the long term.

Aldosterone↗
PubMed1981

The acute effects of sustained volume expansion on the renin-aldosterone system and renal function in human hepatic ascites.

To investigate the acute effect of sustained volume expansion in patients with chronic hepatic ascites, renal and hemodynamic studies were performed on six patients receiving the peritoneovenous shunt. Within 1 hr of shunt insertion, the cardiac output rose by 20% to 60% above the preoperative level and the renal blood flow by 70% to 300%. At the same time both the plasma renin activity and serum aldosterone levels fell to a mean of 34% of the preoperative levels. The urine output increased from fourfold to 38-fold, but the sodium excretion increased in only two of the six patients. The data show that the acute effect of sustained volume expansion is predominantly on water rather than on sodium excretion. This manoeuver acutely suppressed circulating renin and aldosterone levels; however, the blunted natriuretic response suggests that other factors are involved in the sodium retention in these patients.

Aldosterone↗