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Biomedical subjects

J A Knol

Publications and source records attributed to J A Knol.

67 records · Page 4Linked to original sources
PubMed1983

Management of spontaneous umbilical hernia disruption in the cirrhotic patient.

Umbilical hernia is a common finding in cirrhotic patients with ascites. Spontaneous disruption of the hernia and attendant discharge of ascitic fluid is an unusual and rarely reported complication in these patients and is associated with an overall mortality rate of nearly 30%. During the 5-year period 1977-1982, nine patients with hepatic cirrhosis and ascites were treated for spontaneous rupture of an umbilical hernia. Ascites was attributed to alcoholic cirrhosis in all cases and was present for an average of 21 months prior to rupture. In two cases, failed peritoneovenous shunts resulted in reaccumulation of massive ascites. Initial management included sterile occlusive dressings, fluid repletion, and intravenous antibiotic administration. Hernia repair was performed an average of 4.2 days after rupture. General anesthesia was used in eight cases and local anesthesia in one case. In one instance, the hernia became incarcerated and required urgent repair. Postoperative complications, including wound infection and colonic dilatation, occurred separately in two patients (22%). One patient died of hepatic failure 28 days after operation, for an overall mortality rate of 11%. Surviving patients have been followed for an average of 8 months, and most have done well. Spontaneous rupture of umbilical hernia in patients with ascites occurs uncommonly. Operative management is indicated uniformly and can be conducted safely when the patient's condition has stabilized. The prognosis is favorable for patients with good hepatic reserve.

Adult↗
PubMed1983

Remedial surgery following failed gastroplasty for morbid obesity.

Gastroplasty (GP) or gastric bypass with exclusion of 90% of the distal stomach (GBP) have largely replaced small bowel bypass in the surgical management of morbid obesity. Despite the theoretical advantages of GP over GBP, revision rates of up to 20% are reported with GP because of unsatisfactory weight loss resulting from staple line disruption, pouch dilatation, and/or stomal enlargement. This report describes four alternative surgical approaches to failed GP. "Complete" partitioning of the stomach accompanied by gastrogastrostomy or conversion to Roux-en-Y GBP is recommended. Because of intangible advantages associated with exclusion of the stomach and duodenum, conversion to GBP is favored over GP revision in such cases.

Adult↗
PubMed1983

Noncirrhotic portal hypertension: differing patterns of disease in children and adults.

Of 440 patients who underwent operative portal decompression to control variceal hemorrhage, 25 (6%) had histologically verified noncirrhotic portal hypertension (NCPH). A review of these patients identified two distinct patterns of disease. Fourteen children with an average age of 8.5 years were treated with no deaths at operation. Occlusion of the portal vein (PV) was demonstrated preoperatively or intraoperatively in 10 children (71%). Follow-up for 12 to 207 months showed that no children died of a liver-related illness and only one child (7%) developed portal-systemic encephalopathy (PSE). In contrast, 11 adults with an average age of 56 years were treated with an operative mortality rate of 18%. Occlusion of the PV was demonstrated angiographically in four adults (35%). Of nine surviving adults who were followed for 12 to 164 months, five adults (56%) manifested PSE. Intraoperative liver biopsy specimens were analyzed by light microscopy in all cases. With the possible exception of sinusoidal fibrosis and dilatation of intrahepatic portal venous radicles, no histologic discriminators of adult forms versus childhood forms were identified regardless of the status of the PV. We conclude that age stratification in patients with NCPH may provide important prognostic data regarding survival rates and the incidence of PSE after portal-systemic shunting.

Adolescent↗
PubMed1983

Common bile duct strictures associated with chronic pancreatitis.

Common bile duct (CBD) strictures associated with chronic pancreatitis may cause significant hepatobiliary disease. Nine patients with chronic alcohol-related pancreatitis and CBD obstruction requiring operative biliary or pancreatobiliary decompression are reported. Alkaline phosphatase was the most specific biochemical indicator of cholestasis. Abnormal CBD anatomy was delinated accurately in 89 per cent of cases with percutaneous transhepatic cholangiography (PTC) and endoscopic retrograde cholangiopancreatography (ERCP). All strictures were localized to the intrapancreatic portion of the distal CBD. Pancreatic pseudocysts (PPC) were identified in six (67%) cases. All nine patients underwent biliary decompression. Simultaneous PPC drainage or pancreatic duct decompression (Peustow procedure) was performed in eight cases (89%). No perioperative mortality occurred, and all patients reported subjective improvement in symptoms. Biliary tract strictures sufficient to cause clinical or biochemical cholestasis are a poorly recognized complication of chronic pancreatitis. Cholangiography (PTC or ERCP) should be obtained in order to delineate radiographic features, and extent and severity of the biliary stricture because there is no predictable correlation between levels of serum alkaline phosphatase and liver histopathology. A percutaneous biopsy is requisite to document changes in hepatic morphology. In order to prevent potential hepatobiliary complications such as cholangitis and secondary biliary cirrhosis, biliary strictures should be managed surgically even in anicteric and otherwise asymptomatic patients. Simultaneous treatment of associated pancreatic pathology can be performed if necessary with little added morbidity.

Adult↗
PubMedDate not supplied

Dual-phase helical CT of nonfunctioning islet cell tumors.

PURPOSE: The aim of this study was to evaluate the utility of dual-phase imaging in the assessment of nonfunctioning islet cell tumors (NFITs). METHOD: Six patients with histologically and biochemically proven NFIT were evaluated by arterial and portal venous dual-phase helical CT. Scan delay was 20 s for the arterial phase and 70 s for the portal phase. Each phase was assessed by consensus reading and specifically evaluated for tumor conspicuity, hepatic metastases, vascular encasement by tumor, and presence of lymphadenopathy. RESULTS: Overall, tumor conspicuity was greater in the arterial phase (5/6) than in the portal venous phase (1/6) with a mean tumor/normal pancreas attenuation difference of 31.8 HU in the arterial phase compared with 19.2 HU in the portal venous phase. The arterial phase detected a total of 17 liver metastases compared with 9 seen in the portal phase. Lymph node enlargement was noted in three patients, which, although visible in both phases, was more easily discernible in the arterial phase. Venous encasement by tumor was better evaluated on the delayed portal venous phase than the arterial phase. CONCLUSION: Dual-phase helical CT scanning leads to improvement in the detection and staging of NFITs.

Adult↗
PubMedDate not supplied

Dual-phase helical CT of nonfunctioning islet cell tumors.

PURPOSE: The aim of this study was to evaluate the utility of dual-phase imaging in the assessment of nonfunctioning islet cell tumors (NFITs). METHOD: Six patients with histologically and biochemically proven NFIT were evaluated by arterial and portal venous dual-phase helical CT. Scan delay was 20 s for the arterial phase and 70 s for the portal phase. Each phase was assessed by consensus reading and specifically evaluated for tumor conspicuity, hepatic metastases, vascular encasement by tumor, and presence of lymphadenopathy. RESULTS: Overall, tumor conspicuity was greater in the arterial phase (5/6) than in the portal venous phase (1/6) with a mean tumor/normal pancreas attenuation difference of 31.8 HU in the arterial phase compared with 19.2 HU in the portal venous phase. The arterial phase detected a total of 17 liver metastases compared with 9 seen in the portal phase. Lymph node enlargement was noted in three patients, which, although visible in both phases, was more easily discernible in the arterial phase. Venous encasement by tumor was better evaluated on the delayed portal venous phase than the arterial phase. CONCLUSION: Dual-phase helical CT scanning leads to improvement in the detection and staging of NFITs.

Adult↗
PubMedDate not supplied

The changing role of surgery for sclerosing cholangitis.

Primary sclerosing cholangitis is a chronic cholestatic disease that may ultimately progress to hepatic parenchymal dysfunction and death from premature liver failure. Symptomatic patients should undergo radiological evaluation to exclude secondary causes of cholangitis and to evaluate the extent and location of biliary ductal disease. A percutaneous liver biopsy is advisable in any patient with clinical or biochemical evidence of cirrhosis. Patients with diffuse ductal involvement should initially receive medical treatment, preferably in a center conducting prospective clinical trials. Liver transplantation should be considered the initial procedure in primary sclerosing cholangitis patients with diffuse ductal involvement, complications of cirrhosis or deteriorating liver function. Nontransplant procedures should be restricted to symptomatic patients with a dominant extrahepatic stricture. In properly selected patients, effective and durable palliation of symptoms can be anticipated with biliary enteric drainage. Many currently available techniques obviate the need for longterm transanastomotic stenting, thus minimizing the risk of recurrent cholangitis and the need for repeated tube changes. These patients may also be candidates for percutaneous or endoscopic balloon cholangioplasty. Liver transplantation should also be considered in patients with a dominant stricture and histologic evidence of biliary cirrhosis or hepatic deterioration following a nontransplant procedure.

Catheterization↗
PubMedDate not supplied

Efficacy of two comparative antibiotic regimens in the treatment of serious intra-abdominal infections: results of a multicenter study.

A multicenter, open-label randomized trial was conducted to evaluate the efficacy and tolerability of monotherapy with imipenem-cilastatin (I-C) compared with combination therapy with clindamycin and an aminoglycoside (C+A) for treatment of 117 patients with serious intra-abdominal infections. Fifty-three patients (45%) received I-C and 64 patients (55%) received C+A. The overall clinical success rate was 96.2% for the I-C patients and 92.2% for the C+A patients. Clinical failure rates were 3.8% and 7.8%, respectively (P = NS). Eradication or suppression of pathogens was observed in 81.8% and 82.2% of patients, respectively. Uniform bacteriologic response was observed among all infection subgroups. Fourteen of 145 patients experienced adverse symptoms, including six of 66 (9.1%) monotherapy patients and eight of 79 (10.1%) combination-therapy patients (P = NS). The results of this study demonstrate that I-C monotherapy was as effective as C+A combination therapy for the treatment of serious intra-abdominal infections, regardless of the site or severity of infection or the clinical status of the patient. Both regimens also were found to be comparable in tolerability.

Abdomen↗