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Biomedical subjects

J H Ranson

Publications and source records attributed to J H Ranson.

At least 55 records · Page 3Linked to original sources
PubMed1979

The timing of biliary surgery in acute pancreatitis.

The timing of biliary surgery remains controversial in patients with acute pancreatitis associated with cholelithiasis. Eighty hospital admissions for acute pancreatitis, occurring in 74 patients with cholelithiasis, have therefore been reviewed. Among 22 patients who underwent abdominal surgery during the first week of treatment, there were five deaths (23%) and four patients (18%) who required more than seven days of intensive care. Fifty-eight episodes of pancreatitis were managed nonoperatively during the first week of treatment, with no deaths, although six (10%) required more than seven days of intensive care. Biliary surgery was undertaken later during the same admission in 37 patients, with no deaths. Twenty-one patients were discharged without biliary operation, but seven (33%) developed further pancreatitis. Previously reported prognostic signs were used to divide pancreatitis into 57 "mild" episodes (1.8% mortality) and 23 "severe" episodes (17% mortality). Early (day 0-7) definitive biliary surgery was undertaken in 11 patients with "mild" pancreatitis, with one death (9%), and in six patients with "severe" pancreatitis, with four deaths (67%). In three recent patients with "severe" pancreatitis, early biliary surgery was limited to cholecystostomy, with no deaths. These findings suggest that although early correction of associated biliary disease may be undertaken safely in many patients with "mild" acute pancreatitis, early definitive surgery is hazardous in "severe" pancreatitis and should, if possible, be deferred until pancreatitis has subsided. In most patients biliary surgery should precede hospital discharge.

Abdomen↗
PubMed1978

The role of peritoneal lavage in severe acute pancreatitis.

Encouraged by reports of the therapeutic efficacy of peritoneal lavage in small series of five or six patients with acute pancreatitis, we have evaluated this treatment in 24 patients with "severe" pancreatitis. One hundred and three patients with "severe" pancreatitis (28% mortality) were separated from 347 with "mild" pancreatitis (0.9% mortality) by previously described early objective signs. Early treatment (Day 0-7) of "severe" pancreatitis included peritoneal lavage through catheters placed nonoperatively in 18 (Group A) and by catheters placed at laparotomy in six (Group C). Early treatment of nonlavaged patients with "severe" pancreatitis was by standard nonoperative measures in 61 (Group B) and included early operation in 18 (Group D). Lavage was continued for 48-96 hours, usually using 36-48 L/24 hours of balanced isotonic dialysate fluid, and was uncomplicated. Lavage led to striking immediate clinical improvement and no lavaged patient (Groups A and C) died during the first 10 days of treatment of pancreatitis. By contrast, 45% of deaths in nonlavaged patients (Group B and D) occurred during this early period, usually from cardiovascular or respiratory failure. Although lavage reduced mortality in subgroups of patients, ultimate overall survival was no affected (Group A, 83%; B, 84%; C, 33%; D,33%). Late peripancreatic abscesses caused most deaths in lavaged patients. These data show that peritoneal complications of severe acute pancreatitis and dramatically reduces early mortality. Lavage does not prevent the late local sequelae of peripancreatic necrosis.

Abscess↗
PubMed1978

Abdominosacral resection for carcinoma of the midrectum: ten years experience.

Abdominosacral resection allows curative resection of midrectal cancer with excellent preservation of sphincter function. In the last ten years 427 patients underwent resection for rectal carcinoma at University Hospital by one surgeon. (SAL) The operation, selected by preoperative sigmoidoscopic measurement, was anterior resection (AR) in 239, abdominosacral resection (ASR) in 100, and abdominoperineal resection (APR) in 88. Operative mortality was 1.7% for AR, 2% for ASR and 2.3% for APR. All patients were completely continent of stool and flatus after AR and ASR. Follow-up is complete in 194 of 195 patients treated five to ten years ago. Five year survival for curative resection (no distant metastases) was 67.3% after AR (66/98), 58.3% after ASR (21/36), and 50% after APR (15/30). For patients without tumor in lymph nodes, survival rates were 78.3% for AR, 64.3% for ASR and 63.2% for APR. With involvement of regional nodes, survival fell to 41.4% for AR, 37.5% for ASR and 27.3% for APR. For lesions at 5-8.5 cm, five year survival was 61.1% for ASR and 58.3% for APR. No statistical difference in survival time was noted when patients were matched for age, sex, level of lesion and extent of spread. Pelvic recurrences were detected in 16.7% after ASR, 15.3% after AR and 33.3% after APR. All of the pelvic recurrences after ASR and the majority of those after AR and APR occurred in patients with tumor invasion of perirectal fat. These data strongly support the applicability of ASR as an important advance in the treatment of midrectal cancer. Although technically demanding, ASR has permitted preservation of anal continence without sacrifice of long-term cure in approximately 50% of patients who would otherwise have required APR.

Abdomen↗
PubMed1977

Resection of the perforated segment. A significant advance in treatment of diverticulitis with free perforation or abscess.

As a result of improved medical management of chronic diverticular disease, perforation has become the most common indication for surgical intervention. During the past five years sixty-three patients underwent operation for colonic diverticular disease, of which forty-six were for perforation (generalized peritonitis in 8, abscess in 30, and fistula in 8). The eight patients with generalized peritonitis underwent emergency exploration for spreading peritoneal signs and were managed by resection of the perforated segment, end colostomy, and mucous fistula or Hartmann's pouch. Treatment of thirty-eight patients with abscess or fistula has also stressed primary resection of the perforated segment of colon. Resection and end colostomy without anastomosis was performed in three. Primary anastomosis with proximal diverting colostomy was performed in four. Primary anastomosis alone was done in thirty-one patients. There were no deaths. These results support primary resection of the involved colon with immediate or delayed anastomosis in the operative management of perforated diverticular disease.

Abscess↗
PubMed1977

The relationship of coagulation factors to clinical complications of acute pancreatitis.

Alterations in coagulation factors have been reported during acute pancreatitis. Therefore the relationship of coagulation measurements to complications of pancreatitis was evaluated prospectively in 35 patients in whom 130 serial coagulation profiles were performed, consisting of fibrinogen, platelet count (PC), fibrinogen-fibrin-related-antigen (FR-antigen), prothrombin time (PT), partial thromboplastin time, thrombin time, euglobulin clot lysis, and Factors II, V and VII-X levels. During attacks of acute pancreatitis, over-all mean initial fibrinogen and PC of 268 mg. per 100 ml. and 214,000 per cubic millimiter rose significantly (p less than 0.005) to peaks of 362 mg. per 100 ml. and 477,800 per cubic millimeter by day 6 to 10. Mean initial FR-antigen of 4.8 microgram per milliliter rose to peak 7.4 microgram per milliliter on day 5. In 21 patients with mild pancreatitis, mean highest fibrinogen, PC, FR-antigen, and PT were 329 mg. per 100 ml., 361,500 per cubic millimeter, 5.3 microng per milliliter and 14.1 seconds. These values were significantly higher (p less than 0.05 to 0.01) in patients with severe pancreatitis, being 422 mg. per 100 ml. 528,000 per cubic millimeter, 13.7 microng per milliliter, and 15.5 seconds, respectively. Evaluation of the relationship of coagulation measurements to early clinical features showd that mean initial fibrinogen levels were significantly higher (p less than 0.05 to 0.01) in patients with initial amylase greater than 1,000 Somogyi units percent, serum glutamic oxaloacetic transaminase (SGOT) greater than 250 S.F.U. percent, and initial 72 hour PAO2 less than 75 mm. Hg. Early hypoxemia also correlated (p less than 0.05) with elevated initial FR-antigen levels. Impaired early renal function correlated (p less than 0.01) with elevated initial PC only. Early hypocalcemia did not correlate with coagulation measurements. These findings demonstrate that marked changes in coagulation parameters occur during acute pancreatitis and are related to over-all morbidity. Correlation of early coagulation measurements with amylase levels and with respiratory, renal, and hepatic dysfunction suggests that enzyme-related intravascular coagulation may be implicated in the pathogenesis of these complications of pancreatitis.

Acute Disease↗
PubMed1977

Prevention, diagnosis, and treatment of pancreatic abscess.

Since pancreatic abscesses are a highly lethal complication of acute pancreatitis, factors influencing the genesis of major peripancreatic infection (MPI) were analyzed in 330 patients with pancreatitis. MPI developed in 28 (8.5%). Management of MPI was reviewed in 35 patients, including seven admitted with MPI. Etiology and severity of pancreatitis influenced MPI frequency. MPI was common in postoperative pancreatitis (39%), compared with alcoholic (6.6%), biliary (3.6%), or other causes (15%). "Severity" of pancreatitis was estimated by 11 early prognostic signs, which were reported previously. With fewer than three signs, MPI developed in 2.7%, three to five signs, 32%; more than five signs, 50%. Treatment of pancreatitis also influenced MPI. Early laparotomy increased MPI incidence from 1.6% to 23% in mild pancreatitis and from 24% to 67% in severe pancreatitis. Early oral feeding also appeared to predispose to MPI. Prolonged nasogastric suction and avoidance of early operation reduced MPI incidence from 16% in the first 100 patients to 5% in the next 230 patients. Outcome of MPI reflected severity of underlying pancreatitis. Mortality with fewer than three signs was 14%; with three to five signs, 65%; with more than six signs, 100%. Mortality was only 26% in 19 patients treated with radical sump drainage of the entire peripancreatic retroperitoneum, compared to 75% of 16 patients treated with conventional local drainage. In summary, MPI is related to etiology and severity of pancreatitis as quantified by early signs. Early laparotomy for pancreatitis increased MPI. Treatment of MPI with wide sump drainage appears more effective than local drainage.

Abscess↗
PubMed1976

Perforated diverticula of the jejunum and lleum.

Over a ten year period, four patients with inflammation or perforation of non-Meckelian, small intestinal diverticula were treated on the surgical services of Bellevue Hospital. This entity remains uncommon but may be increasing in incidence. The patients presented with a short history of severe abdominal pain, usually accompanied by nausea and vomiting. Each patient also gave a longer preceding history of less well defined abdominal symptoms. The pathogenesis of the small intestinal diverticula is uncertain but may be related to disturbed muscular peristalsis in the small bowel analogous to the changes implicated in esophageal and colonic diverticular disease. The diverticulum may be difficult to demonstrate at operation, and careful exploration for this possibility should be carried out at the time of operation for peritonitis of obscure origin. Segmental resection and end-to-end anastomosis is the treatment of choice.

Adult↗
PubMed1976

Pulmonary capillary permeability - a transfusion lesion.

Massive transfusion of bank blood has been implicated as a major etiologic factor in the evolution of pulmonary insufficiency after injury. In spite of the demonstration of significant debris, including aggregates, in stored blood, a precise and reproducible pulmonary effect of transfusion has not previously been demonstrated. Since clinical pulmonary insufficiency is frequently accompanied by increased lung water, these experiments were designed to measure pulmonary capillary permeability and its response to transfusion of blood and blood components in rats. These experiments demonstrate that: 1) the rat lung is a target organ with regard to blood transfusion; 2) the lung lesion with transfusion is attributable, at least in part, to a selective and acute increase in pulmonary capillary permeability; 3) pulmonary capillary permeability is highly responsive to viable platelets; 4) prolonged storage of blood in polyvinyl chloride containers may enhance its ability to induce pulmonary capillary permeability; 5) increased capillary permeability with transfusion is largely eliminated when platelets and buffy coat are eliminated.

Animals↗
PubMed1976

Prognostic signs and nonoperative peritoneal lavage in acute pancreatitis.

Three hundred patients with acute pancreatitis have been studied. Pancreatitis was associated with alcoholism in 207, biliary tract disease in 51 and other conditions in 42. Twenty-two patients died, and an additional 34 patients required more than one week of treatment in the intensive care unit. Retrospective analysis of the first 100 patients identified 11 objective findings which correlated with the occurrence of serious illness or death. They were, on admission, age over 55 years, blood glucose level over 200 milligrams per cent, white blood count over 16,000 per cubic millimeter, serum lactic dehydrogenase level over 350 International units per liter and serum glutamic-oxalacetic transaminase level over 250 Sigma Frankel units per cent. During the initial 48 hours of therapy, the findings were hematocrit value decrease over 10 percentage points, serum calcium level below 8 milligrams per cent, base deficit over 4 milli-equivalents per liter, a blood urea nitrogen level increase over 5 milligrams per cent, estimated fluid sequestration over 6 liters and arterial oxygen tension less than 60 millimeters of mercury. Prospective application of these signs in the latter 200 patients permitted the accurate early identification of those with severe pancreatitis. Only one of 162 patients with fewer than three of these early features was seriously ill or died, while 24 of 38 patients with three or more early positive findings were seriously ill or died. The objective early identification of patients with severe pancreatitis permits more vigorous management of this group and also provides a basis for the selection of patients for the evaluation of proposed improved therapies. Percutaneous peritoneal dialysis in severe pancreatitis was evaluated in ten patients, with three or more positive early signs, who were randomly assigned to dialysis or continued conventional care. Morbidity was strikingly reduced in patients who underwent dialysis, and while death or more than nine days of intensive care occurred in two of five patients who did not receive dialysis, all five patients having dialysis recovered after fewer than nine days of intensive care treatment. Serious illness or death occurred in 31 of the first 100 patients but in only 26 of the more recent 200 patients. There has been a similar fall in mortality from 15.0 to 3.5 per cent. Factors which may contribute to this improvment include the objective early identification of patients with severe disease, the avoidance of early laparotomy whenever practical, the prolongation of nasogastric suction until all evidence of pancreatic inflammation has resolved, careful monitoring of respiratory function and early treatment of pulmonary complications and peritoneal dialysis in patients with severe disease.

Acute Disease↗
PubMed1975

Villous tumors of the duodenum.

Villous tumors of the duodenum are rare, but treatment may be problematic because of their association with invasive adenocarcinoma. Two cases of villous tumor of the duodenum are described and 39 other reported cases are reviewed. Presenting symptoms were bleeding 27%; obstruction 24%; jaundice 22% and vague dyspepsia 20%. Diagnosis may be made by radiographic barium contrast evaluation of the duodenum, especially with the addition of air contrast hypotonic studies and by fibro-optic endoscopy. Twenty-seven per cent of villous tumors of the duodenum are associated with adenocarcinoma. Invasive tumor is more common in patients over 50 years old (35%), in tumors of the third and fourth portions of the duodenum (44%) and in tumors over 4 cm in diameter (30%). Local excision is the treatment of choice for benign lesions. Pancreatico-duodenectomy is recommended for tumors which include invasive carcinoma in patients without distal metastases.

Adenocarcinoma↗
PubMed1975

New diagnostic and therapeutic techniques in the management of pyogenic liver abscesses.

An unexplained increase in the frequency of pyogenic liver abscesses of unknown etiology has, fourtunately, been paralleled by significant advances in diagnostic and therapeutic methods. This report reviews experience with 14 patients operated upon at NYU Medical Center since 1971. Eight cases (57%) were cryptogenic. Other abscesses were associated with biliary disease (3); abdominal sepsis (2); and trauma (1). Abscesses were present on hospitalization in 12 patients. Clinical findings included fever (101-108 F); 100%; leucocytosis, 71%; anorexia and vomiting, 50%; localized tenderness and hepatomegaly, 50%; hypoalbuminemia, 86%; hypocholesterolemia, 78%; elevated SGOT, 71%; and elevated aikaline phosphatase, 43%. Technetium hepatic scintiscans showed focal defects in 10 of 12 patients (83%), but did not detect multiple abscesses in 2 of these. Hepatic arteriography performed in 10 patients was highly accurate, outlining single abscesses in 6 and multiple abscesses in 4. Furthermore, in one patient a false positive scintiscan was demonstrated by negative arteriography, confirmed by autopsy. In 4 patients, arteriography indicated an abscess in the posterior-superior area of the right hepatic lobe. With precise anatomical localization, a trans-thoracic approach permitted uncomplicated drainage in each case. This approach provides excellent exposure and direct drainage for abscesses in this area. An additional therapeutic adjunct in two patients, with 4 and 11 abscesses each, was postoperative intraportal infusion of antibiotics through the umbilical vein. Thirteen patients (83%) recovered, one dying from pulmonary embolism. Primary hepatic abscesses occur with increasing frequency. Primary hepatic abscesses occur with increasing frequency. Primary hepatic abscesses occur with increasing frequency. The methods described allow more precise preoperative diagnosis and direct surgical drainage.

Adult↗
PubMed1974

The influence of DL-A compatibility on the survival of hepatic allografts in unmodified mongrel dogs.

Heterotopic hepatic transplantation was performed in 26 pairs of littermate and non-littermate mongrel dogs selected by serological criteria of DL-A compatibility. No immunosuppression was given. In non-littermates, 11 recipients of DL-A incompatible allografts survived 10-22 days (mean 13.4 days). Mean serum bilirubin rose by the 6th day. Three recipients of DL-A compatible allografts survived 13, 41, and 60 days, (mean 38 days). Mean serum bilirubin rose by the 8th day. In littermates, 5 recipients of DL-A incompatible allografts survived 7-12 days (mean 10.2 days) and mean serum bilirubin rose by the 6th day. Four recipients of DL-A compatible allografts from phenotypically DL-A non-identical donors survived 58, 82, 90 and 128 days (mean 89.5 days). Mean serum bilirubin rose by the 29th day. In contrast, 3 recipients of DL-A phenotypically identical allografts survived 171, 536 and over 636 days respectively, with normal mean serum bilirubin levels. The results confirm the role of the DL-A system in hepatic transplantation in mongrel dogs, and suggest that this dog population may constitute a suitable experimental model parallelling the current situation with regard to HL-A compatibility testing in outbred human subjects. The relatively long survival of DL-A compatible heterotopic hepatic allografts, compared with similar transplants of skin, kidney and heart, also suggests a need for studies of possible alteration in parameters of humoral and cellular reactivity in these recipients.

Animals↗