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Biomedical subjects

J C Gruenberg

Publications and source records attributed to J C Gruenberg.

At least 19 recordsLinked to original sources
PubMed2000

Isolated small gallbladder polyps: an indication for cholecystectomy in symptomatic patients.

To evaluate patients with gallbladder polyps and to compare them with patients with chronic acalculous cholecystitis, 301 patients with chronic acalculous disease of the gallbladder, of which 45 had polyp disease of the gallbladder, were reviewed out of 7181 cholecystectomies performed from June 1985 through June 1995. Of the 45 patients, 30 (Group A) were diagnosed preoperatively by ultrasound and 15 (Group B) postoperatively on pathologic examination. In each group, the most common polyp was cholesterol type (19/45) with multiple lesions in 10 of these 19 patients. Chronic cholecystitis was present elsewhere in the gallbladder in 40 per cent of Group A and 80 per cent of Group B patients (P = 0.02). Forty-three patients had polyps less than 5 mm in diameter, one a 1.5-cm gallbladder cholesterol polyp, and one a 1.3-cm tubulovillous polyp with a focus of carcinoma in situ. During this same period, 17 patients had primary malignancy of the gallbladder, none of which were found in polypoid lesions. In Group A patients there were significantly fewer preoperative tests than in typical acalculous patients [2.3 versus 3.8 (P<0.03)], including upper endoscopy (P<0.02) and hepatobiliary scintigraphy (P<0.00001). Of the patients with polyps, 42 of 45 (93.3%) had resolution of symptoms postoperatively with a mean follow-up of 178.9+/-505.0 days (range 1-2438 days). Most patients with biliary tract symptoms and a small (<5-mm) gallbladder polyp underwent fewer preoperative diagnostic tests than patients with chronic acalculous cholecystitis. This abbreviated preoperative workup appears warranted in view of the high incidence of symptom resolution.

Adult↗
PubMed1998

Bile duct injuries during laparoscopic cholecystectomy: a community's experience.

Reports of bile duct injuries are from tertiary care institutions and, therefore, may not report the spectrum of management that these patients receive in the care of these injuries. From June 14,1990 (the first operation) to June 30, 1995, 2654 laparoscopic cholecystectomies (LCs) were reviewed at this community hospital medical center to determine risk factors contributing to the etiology of these injuries, time and symptoms at presentation, duration of illness, and management of these injuries. None of the 13 general surgeons practicing during this time period had laparoscopic training in a general surgical residency. There were six major bile duct injuries (0.25%), of which five were available for further review. All occurred in women with cholelithiasis and chronic cholecystitis. Two operations were routine and two were associated with biliary tract anomalies. In two patients, the injuries were detected at LCs and definitive biliary-enteric anastomoses were performed immediately. Three patients presented at 2, 15, and 42 days after LC. In two patients, one or more operative procedures were performed before definitive repair and these patients were referred to tertiary care centers. One patient was managed with sequential CT-guided drainage catheters after attempted closure of the defect. The length of illness for these five patients was 8, 69, 348, 402, and 435 days with a follow-up of 245, 345, 531, 575, and 1088 days. Laparoscopic experience before injury by the operating surgeon was 3, 26, 35, 77, and 333 operations. Major biliary tract injuries occurred during routine cholecystectomy, length of illness was substantial for most patients, and biliary-enteric anastomosis was definitive for four of the five patients. The operating surgeons' "learning curve" did not seem as important as in other studies.

Adult↗
PubMed1998

The changing face of cholecystectomy.

Previous reports in selected patient populations have noted an increase in the number of cholecystectomies since the introduction of laparoscopic cholecystectomy. To assess the impact of laparoscopic cholecystectomy in a more general population, 6473 consecutive cholecystectomies from 7/1/86 to 6/30/95 were reviewed to assess changes in rate of cholecystectomy, diagnosis leading to cholecystectomy, and general patient demographics. During the 9-year period, the number of cholecystectomies increased from 618 to 800 per year (29%; P < 0.002). Even more striking was the redistribution of cholecystectomies performed for acalculous disease (P < 0.0001), with the rate of increase more than doubling for each individual diagnosis (biliary dyskinesia, 348%; acute acalculous cholecystitis, 139%; chronic acalculous cholecystitis, 138%). When comparing patient characteristics, there was a significant increase in the number of cholecystectomies performed on females when compared with males. When compared with other races, whites underwent cholecystectomy for chronic acalculous cholecystitis at a higher rate (120%; P < 0.0003). The introduction of laparoscopic cholecystectomy was followed by a dramatic increase in cholecystectomies performed for acalculous disease and less so for cholelithiasis. Accompanying the increase were significant alterations in patient demographics. The study provides indirect evidence for lowering thresholds and changing indications with reasons for the increases yet to be determined.

Cholecystectomy↗
PubMed1995

Complications of laparoscopic cholecystectomy after hospital discharge.

In this community hospital medical center, all patients undergoing laparoscopic cholecystectomy (LC) who had a subsequent emergency room visit or hospital admission were reviewed to define the incidence and presentation of complications after hospital discharge. This unselected population, which is isolated geographically, provides a useful approximation of mortality and morbidity after hospital discharge. Of 1231 patients, 800 (65%) had no subsequent hospitalization or emergency room visit within a 6-32-month follow-up, whereas 431 (35%) did. Fifty-six (4.6%) patients had surgical complications related to their LC. The most serious complications were myocardial infarction (n = 1, the only death), common duct stricture (n = 2), retained common duct stone (n = 2), cystic duct leak (n = 2), subhepatic fluid collection or abscess (n = 3), pancreatitis (n = 3), and pulmonary (n = 5). Abdominal pain was the most common presenting symptom (62%), and 72% (42/56) occurred within 14 days, whereas, only 4% (15/375) patients with nonsurgically related complications presented within 14 days. In this study, emergency room visits and hospitalizations after LC occurred more commonly (35%) than generally appreciated, were usually minor, and were not related to the operative procedure, but serious late surgical complications occasionally appeared weeks to months postoperatively.

Abdominal Pain↗
PubMed1993

Fournier's gangrene: historic (1764-1978) versus contemporary (1979-1988) differences in etiology and clinical importance.

Experience with 11 cases of Fournier's gangrene during the decade 1979-1988, prompted this review of the English language literature to determine whether there have been changes in demography, etiology, and outcome, as compared to cases dating to 1763. All cases were evaluated according to age, sex, bacteriology, etiology, and outcome. In the decade 1979-1988, 449 cases were reported. The average age of the patients was 49.8 years; with 14 per cent occurring in females. Synergistic polymicrobial infections were present in all cases. The most commonly reported etiologies were colorectal (33%), idiopathic (26%), and genitourinary (21%). Mortality associated with colorectal etiology was highest (33%, p < 0.05). Female mortality (49%) was not significantly greater than male mortality (17%), when obstetrical etiology was excluded. Overall mortality was 22%. Comparison with 386 cases of Fournier's gangrene reported between 1763 and 1978 reveals that the mean age of patients remains relatively low, and males continue to predominate. The pathophysiologic aspects of this disease appear similar in both sexes. The mortality rate from colorectal sources is significantly greater than from other common causes. Neither the introduction of antibiotics nor the development of newer ones has reduced mortality significantly. In spite of newer diagnostic techniques, the etiology remains unclear in over one-fourth of cases.

Fasciitis↗
PubMed1992

A quantitative, qualitative, and critical assessment of surgical waste. Surgeons venture through the trash can.

OBJECTIVES: To quantitatively and qualitatively evaluate the surgical waste produced from several common surgical procedures, define categories of waste that might be readily separated for alternative disposal practices or substitution, and determine the change in surgical waste output that elimination or alternative handling methods may effect. DESIGN: A case series evaluating the surgical waste from five types of surgical procedures including operations of the back, heart, abdomen, hip and knee, and herniorrhaphies, prospectively identified and allocated at the availability of the investigator. SETTING: A single tertiary community teaching hospital. OUTCOME MEASURES: Weight, volume, and percentage of disposable linen, paper, and plastic plus miscellaneous material from surgical waste with a later subset separating plastics from miscellaneous items to completely identify all categories. RESULTS: Surgical waste weighing 610.5 lb (274.7 kg) and occupying 171.6 cu ft (5.1 m3) from 27 cases was examined. Disposable linens accounted for 39% of the weight; paper, 7%; plastic, 26%; and miscellaneous waste, 27%. By volume, disposable linen and paper accounted for 69%; plastic, 23%; and miscellaneous waste, 7%. Disposable linen, paper, and recyclable plastic accounted for 73% +/- 7% (mean +/- SD) by weight and 93% +/- 4% by volume of total surgical waste. CONCLUSION: Nationally, annual surgical waste from these five procedures weighs 5.1 x 10(7) lb (2.3 x 10(7) kg) and occupies 1.4 x 10(7) cu ft (4.0 x 10(5) m3). By using reusable linen products and engaging in recycling methods currently available and feasible, we estimate that weight reductions of 73% and volume reductions of 93% in surgical waste are possible.

Disposable Equipment↗
PubMed1989

Prospective evaluation of C-reactive protein in patients suspected to have acute appendicitis.

C-reactive protein (CRP) was measured in 70 consecutive patients hospitalized with the diagnosis of acute appendicitis. Of these, 28 patients (Group 1) had acute appendicitis, 25 patients (Group 2) had no identifiable focus of infection and improved with general supportive care, and 17 patients (Group 3) had an identifiable cause for their illness, though not appendicitis. CRP level was not helpful in distinguishing among patients in any group when symptoms were present for 12 hours or less. When symptoms were present for more than 12 hours, all patients in Groups 1 and 3 and half of the patients in Group 2 had a significant increase in CRP value. Thus, a normal CRP value in a patient presenting with a duration of symptoms of more than 12 hours occurred only in Group 2; this difference was statistically significant (P less than 0.001). When symptoms are present for more than 12 hours, an increased CRP value supports the diagnosis of acute appendicitis and will identify patients who have signs and symptoms similar to acute appendicitis but who have another identifiable illness. When the CRP value is normal in a patient who has had symptoms for more than 12 hours, this patient does not have acute, appendicitis and can be followed in an outpatient setting.

Acute Disease↗
PubMed1986

Splenectomy in systemic lupus erythematosis.

Of 860 patients with systemic lupus erythematosus (SLE) who were evaluated during a 25-year-period, 16 (1.9%) underwent splenectomy. Twelve of these patients had steroid resistant thrombocytopenia. An excellent long-term outcome occurred in eight (67%), significant improvement occurred in three (25%), and one patient died who also had chronic active hepatitis and portal hypertension. In two of three patients (67%) with autoimmune hemolytic anemia, the condition was corrected by splenectomy; in the third patient there was some improvement, but reduced doses of corticosteroids were required. One patient with severe neutropenia and recurrent bacterial infection obtained lasting benefit following splenectomy. Histologic examination of the removed spleen was not helpful in corroborating the diagnosis of SLE in these well established cases. Splenectomy had no adverse affect upon other aspects of SLE, in particular upon renal function. The authors conclude that the indications for splenectomy have proven to be of value in selected SLE patients with autoimmune or hypersplenic cytopenia.

Adolescent↗
PubMed1983

Delayed splenic rupture: the phoenix.

An emergency splenectomy was necessary 25 days after blunt injury of a patient whose initial peritoneal lavage was negative, whose visceral angiograms were negative, and whose abdomen remained asymptomatic during interval intensive observations. Delayed splenic rupture can occur rarely in the face of extensive diagnostic evaluation.

Humans↗
PubMed1982

Ventricular function in myocardial contusion: a preliminary study.

During a consecutive 17 month period, 15 trauma patients were diagnosed as having a myocardial contusion on the basis of abnormal ECG in 14 patients, elevated creatinine phosphokinase (CPK) in 13 patients, and elevated CPK-Muscle Brain (CPK-MB) isoenzyme determination in 11 patients. Using these screening modalities, the incidence of myocardial contusion in patients with blunt chest trauma increased from 7% when viewed retrospectively to 15% when viewed prospectively. Five patients had determinations of cardiac index of which 4 were less than 2.9 L/min . M2. An additional 9 patients underwent a standard fluid challenge of 500 ml of 5% plasma protein faction infused over 30 min allowing construction of a Starling myocardial performance curve. Of these patients, 6 had biventricular dysfunction, 1 had isolated abnormal left ventricular function, and 2 had isolated abnormal right ventricular function in the absence of chronic obstructive pulmonary disease or preexisting heart disease. Multiple gated acquisition scans (MUGA) were abnormal in 6 patients and normal in 4 patients. Of the latter group, 3 had biventricular dysfunction and 1 had depressed cardiac index. Morbidity and mortality for myocardial contusion occurred in 40% (6 of 15) of patients in this series. Direct hemodynamic measurement with construction of a Starling curve was useful in monitoring the degree of impairment and subsequent recovery of myocardial function. This information was important in delaying semiurgent operations or in determining the best alternative of otherwise equally acceptable methods of patient management.

Adolescent↗
PubMed1982

Spectrum of myocardial contusion.

During a consecutive period of 26 months, 42 patients with blunt chest trauma were diagnosed as having a myocardial contusion on the basis of an abnormal electrocardiogram (ECG) in 36 patients, elevated creatine phosphokinase (CPK) in 39 patients, and positive CPK-Muscle Brain (CPK-MB) isoenzyme in 33 patients. Using these screening modalities, the incidence of myocardial contusion in patients with blunt chest trauma increased from 7 per cent when viewed retrospectively to 17 per cent when viewed prospectively. Eight patients had cardiac index determinations only; of these, three were less than 2.9 1/min/M2. An additional 21 patients underwent a standard fluid challenge of 500 cc of 5 per cent plasmanate infused over 30 minutes allowing construction of a Starling Curve. Five patterns of ventricular function curves were observed. Six patients had biventricular dysfunction, six patients had isolated right ventricular dysfunction, three patients had isolated left ventricular dysfunction, three patients had an "unslope-peak-downslope" pattern, and three patients had normal ventricular function studies. Multiple gated acquisition (MUGA) scans were abnormal in ten patients and normal in 12 patients. Major morbidity and mortality due to myocardial contusion occurred in 17 per cent of the (7/42) patients; of these, three had biventricular dysfunction, one had left ventricular dysfunction, and two had a low cardiac index. This experience suggests that screening tests are sensitive in detecting myocardial contusion in blunt chest trauma, but are not predictive of major morbidity or mortality. Only direct hemodynamic measurement with construction of a Starling Curve was useful in determining the severity of the myocardial injury and identifying those patients at greatest risk.

Adolescent↗
PubMed1982

The diagnostic usefulness of peritoneal lavage in penetrating trauma: a prospective evaluation and comparison with blunt trauma.

In order to assess the relative utility and reliability of peritoneal lavage as an aid in the management of patients with penetrating trauma, 709 patients (353 penetrating; 356 blunt) with trauma to the lower chest and/or abdomen were evaluated prospectively during 23 consecutive months. There were 144 true-positive, 14 false-positive, 524 true-negative, and 27 false-negative lavages for an error rate of 5.8 per cent (41/709). Intra-abdominal injury was present in 27 per cent of 15 patients with shotgun injuries, 54 per cent of 141 patients with gunshot injuries, and 24 per cent of 197 patients with stab wounds. The sensitivity, specificity, and test value of peritoneal lavage in this series was high and comparable in both penetrating and blunt trauma during the initial diagnostic evaluation of the trauma patient. The error rates were comparable in penetrating and blunt trauma; however, false-positive lavages occurred more frequently in blunt trauma and false-negative lavages occurred more frequently in penetrating trauma (p = .0022). Peritoneal lavage can be extremely useful in the initial evaluation of penetrating trauma of all types.

Abdominal Injuries↗