Biomedical subjects
Publications and source records attributed to G Maddern.
A successful method for controlling intractable bleeding after endoscopic sphincterotomy is described. By passing a Fogarty catheter into the duodenum, balloon tamponade of the bleeding point is possible. By such a technique, major resective surgery can be avoided.
The surgical management of portal hypertension depends on the location of the obstruction. Suprahepatic obstruction is usually optimally treated by a surgical portacaval shunt. In extrahepatic obstruction the treatment should be sclerotherapy. For intrahepatic obstruction in emergency situations, sclerotherapy is the first choice, with portacaval systemic shunts or transjugular intrahepatic portal systemic stent shunt the second option. Liver transplantation in other situations should, if possible, be considered ahead of a portal diversion.
A prospective randomized trial of 67 patients undergoing oesophagectomy by either a transhiatal approach or right-sided thoracotomy was conducted over a 40-month period. In 32 patients the approach was transhiatal and 35 had a thoracotomy; the groups were well matched before operation. There were two hospital deaths in patients having the transhiatal oesophagectomy and three in those undergoing thoracotomy. Blood transfusion, intensive care stay and overall time of hospitalization were not significantly different between the two groups. There was no difference in the postoperative morbidity rate and, in particular, the incidences of pulmonary complications were similar (19 per cent for transhiatal oesophagectomy, 20 per cent for thoracotomy) with anastomotic fistula in 6 and 9 per cent respectively. The median (range) operating time was significantly longer in patients having thoracotomy (6 (3.5-9.5) versus 4 (3-8) h). Long-term survival was unaffected by the type of operation performed or addition of preoperative chemotherapy or radiotherapy. Nodal status was a significant prognostic factor within but not between the two groups. It is concluded that oesophagectomy by a transhiatal route or right thoracotomy are equally effective surgical options for treatment of squamous cell oesophageal cancer.
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This study reports major gastrointestinal complications in a group of 416 patients following kidney transplantation. Three hundred and ninety-nine patients received a cadaveric kidney while the other 17 received a living related organ. The immunosuppressive regimen changed somewhat during the course of the study but included azathioprine, prednisolone, antilymphocyte globulin, and cyclosporin. Perforations occurred in the colon (n = 6), small bowel (n = 4), duodenum (n = 2), stomach (n = 1), and esophagus (n = 1). There were five cases of acute pancreatitis, four of upper gastrointestinal and two of lower intestinal hemorrhage, two of acute appendicitis, one of acute cholecystitis, one postoperative mesenteric infarction, and two small bowel obstructions. Fifty percent of the complications occurred while patients were being given high-dose immunosuppression to manage either the early postoperative period or episodes of acute rejection. Ten percent of the complications had an iatrogenic cause. Of the 31 patients affected, 10 (30%) died as a direct result of their gastrointestinal complication. This high mortality appears to be related to the effects of the immunosuppression and the associated response to sepsis. Reduction of these complications can be achieved by improved surgical management, preventive measures, prompt diagnosis, and a reduced immunosuppressive protocol.
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Subtotal esophagectomy may be performed without thoracotomy by transhiatal dissection. We describe an alternative to the classical technique of transhiatal manual blunt dissection of the esophagus using a ring dissector, which allows a less traumatic dissection of the esophagus above the carcinoma of the esophagus. This instrument, designed for this particular purpose, produces a rapid and clean blunt dissection.
In 25 patients, 12 with acute-subacute and 13 with chronic extensive femoropopliteal artery occlusions (mean length, 8 cm), a prospective study was performed after application of the Kensey catheter and subsequent performance of percutaneous transluminal angioplasty (PTA). Passage through the occlusion with the Kensey catheter failed in five patients because of the presence of dissections. As confirmed at angiography, free flow through the obstruction and the runoff bed could be restored with the Kensey catheter, guide wires, balloon dilation, and thrombus aspiration and/or thrombolysis in 24 of the 25 patients (96%). In five patients, peripheral embolisms occurred after application of the Kensey or balloon catheter. Cumulative patency rates, according to findings of a noninvasive examination, were 80% at 3 days, 59% at 6 months, and 38% at 12 months after performance of the combined interventions. Thus, the results obtained with use of this new device have not proved superior to previously reported results with conventional PTA.
The authors report a case of neuroendocrine carcinoma of the lower third of the esophagus. Immunohistochemical study revealed that most tumor cells expressed neuron specific enolase, chromogranin A, carcinoembryonic antigen and glucagon. They insist on the usefulness of this study on biopsies in order to guide therapeutic decision.
We reviewed 314 consecutive patients in whom a Björk-Shiley Monostrut aortic valve prosthesis was inserted by our cardiothoracic surgical unit from June 1982 through June 1986. The group comprised 220 males (70%) and 94 females (30%), with a mean age of 60 years (range, 5 to 83 years). Two hundred ninety-six patients (94%) received an aortic prosthesis alone, and the other 18 (6%) received both an aortic Monostrut valve and a Starr-Edwards mitral valve prosthesis. In each case, preoperative data were collected prospectively, and a questionnaire was sent at the time of follow-up. The median follow-up period was 23 months (range, 0 to 46 months); 6 (2%) of the patients were lost to follow-up. In the remaining 308 cases, there were 20 deaths (6.5%), 8 of which occurred within approximately 1 month after operation. There were no known instances of valve failure. One death occurred in the group that underwent double-valve replacement. Valve endocarditis accounted for 2 late deaths. With respect to preoperative dyspnea, 59 (19%) of the patients were in New York Heart Association functional Class I, 74 (24%) were in Class II, 138 (45%) were in Class III, and 37 (12%) were in Class IV. Postoperatively, there were 247 patients (80%) in Class I, 43 (14%) in Class II, 15 (5%) in Class III, and 3 (1%) in Class IV (p < 0.0001). All of the patients received postoperative anticoagulant therapy; 3.4% per year were subsequently readmitted for bleeding problems. Thromboembolic events necessitating hospitalization occurred in 3.0% of the patients per year. On the basis of these results, our early experience with the Björk-Shiley Monostrut valve in the aortic position has been satisfactory, with an acceptable rate of complications and no documented valve failures.
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Radionuclide techniques have enabled direct quantitative measurements of gastric emptying for solid and liquid phases of a meal. Such a technique has been used to validate the use of plasma paracetamol levels as a means of indirect assessment of liquid gastric emptying and to confirm a useful correlation exists between plasma and saliva paracetamol concentrations. Ten healthy volunteers underwent a routine gastric emptying study. The meal comprised a 100g 'hamburger' and 150 ml of 10% dextrose in water containing 113In and 1 g of dissolved paracetamol. The time taken for 50% of the liquid marker (T50) to clear the gastric region was assessed. Time to peak concentration of paracetamol for both saliva (C max-saliva) and plasma (C max-plasma) was determined. A significant correlation was found between the time to C max-plasma and T50 (rs = 0.624, P less than 0.05) and also time to C max-saliva and T50 (rs = 0.573, P less than or equal to 0.05), confirming that paracetamol concentration in plasma and saliva reflect radionuclide assessed liquid emptying. A useful correlation also exists between time to C max-plasma and time to C max-saliva (rs = 0.84, P less than 0.01) permitting them to be used interchangeably. The use of time to C max-saliva to assess liquid gastric emptying has a number of applications.
CT-guided fine-needle puncture (FNP) was carried out in 74 patients with pelvic masses and resulted in a correct diagnosis in 36/45 patients (80%) with malignant disease. FNP was true-positive in 66.7% and false-negative in 20%. In benign and inflammatory pelvic space-occupying lesions, FNP confirmed the suspected CT diagnosis in all cases by cytology and bacteriology. CT-guided puncture should always be used complementary to CT when a mass of unclear etiology is present.