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Biomedical subjects

J R Starling

Publications and source records attributed to J R Starling.

At least 37 records · Page 2Linked to original sources
PubMed1990

Current status of sphincter preservation in rectal cancer.

Surgical management of rectal carcinoma has progressed during the past decade to a wider utilization of sphincter preservation procedures. As such techniques have been modified and advanced, options for sphincter preservation have been employed to significantly preserve quality of life without adversely affecting patient survival or functional results. The documentation that recurrence of rectal carcinoma is based more upon individual tumor biology than simply wide or radical margins of resection has supported the rationale for sphincter-sparing procedures. The surgical management of rectal carcinoma has moved from traditional radical excision with colostomy to functional preservation in selected patients.

Adenocarcinoma↗
PubMed1989

Tertiary hyperparathyroidism after renal transplantation: operative indications.

A retrospective analysis of our renal transplant population between 1981 and 1987 was undertaken to study the natural history of posttransplant hypercalcemia and to review indications and recommendations regarding the timing of parathyroidectomy. During this period, 1158 renal transplant procedures were performed in 1025 patients, with 819 allografts (71%) functioning currently. Posttransplant hypercalcemia greater than 10.5 mg/dl was associated with a longer duration of dialysis and developed in 227 patients, with onset of hypercalcemia occurring in 90% of these patients by 1 year. In 69% of these patients, spontaneous resolution of the hypercalcemia occurred between 6 months and 7 years after transplantation. A total of 42 patients with asymptomatic hypercalcemia are currently being followed up, with a mean serum calcium level of 11.0 +/- 0.41 mg/dl and a mean follow-up interval of 3.3 +/- 1.6 years since transplantation. Nine symptom-free patients with moderate hypercalcemia (12.0 to 12.4 mg/dl) more than 1 year after transplantation were identified. Five of these patients had spontaneous resolution of the hypercalcemia between 2 and 7 years. Fifteen patients with posttransplant hyperparathyroidism (6.6%) required parathyroidectomy--11 for symptomatic and four for asymptomatic hyperparathyroidism. One patient had symptomatic hyperparathyroidism despite the presence of normocalcemia. One symptom-free patient with significant hypercalcemia (serum calcium level, 14.7 mg/dl) underwent parathyroidectomy 3 months after transplantation. The remaining three symptom-free patients had serum calcium determinations of greater than or equal to 12.5 mg/dl more than 1 year after renal transplantation. Patients with pretransplant and posttransplant hypercalcemia required parathyroidectomy more frequently than did patients with only posttransplant hypercalcemia (18% versus 3.0%; p less than 0.001). An unusual finding was the occurrence of a single adenoma in two patients, which represents sporadic primary hyperparathyroidism in the patient undergoing renal transplantation rather than tertiary hyperparathyroidism. We recommend a conservative approach to posttransplant hypercalcemia, with surgery reserved for patients with symptomatic disease and patients with asymptomatic persistent hypercalcemia greater than or equal to 12.5 mg/dl more than 1 year after transplantation.

Follow-Up Studies↗
PubMed1989

The effects of hypoproteinemia and volume expansion on lung and soft tissue transvascular fluid filtration.

Resuscitation from major trauma or replacement of major operative blood loss frequently results in varying levels of protein depletion and alterations in plasma volume. To assess the importance of these factors on pulmonary and soft tissue transvascular fluid filtration, we compared the effects of hypoproteinemia and plasma volume expansion on the rate of lung and soft tissue transvascular fluid filtration in unanesthetized adult sheep. Ten animals were surgically prepared with chronic lung and soft tissue lymph fistulas. Lung (QL) and soft tissue (Qs) lymph flow rates were used to determine changes in transvascular fluid filtration. Initially, lactated Ringer's solution (LR) was infused to elevate pulmonary arterial wedge pressure of normoproteinemic animals (Norm/LR) 5 mm Hg for 2 1/2 hours. After a plasmapheresis-induced protein depletion of 30% to 35%, similar volume expansions with LR (Hypo/LR) and fresh frozen plasma (Hypo/Plas) were performed. Plasma, lung lymph, and soft tissue lymph oncotic pressures were determined, and transvascular oncotic gradients were calculated. Plasma volume expansion during Hypo/Plas conditions limited (p less than or equal to 0.05, 3 hours after infusion) Qs elevations compared with Hypo/LR expansion. However, there appeared to be no significant advantage with fresh frozen plasma over LR infusion in limiting QL. During fresh frozen plasma infusion, a distinct 10- to 12-hour lag in protein transport into the interstitium was observed in the soft tissue but not the lung microcirculation. The resultant differences in fluid filtration properties were in part the result of significant widening of the oncotic gradient in soft tissue. Plasma protein infusion appeared not to be beneficial over LR in limiting lung transvascular fluid filtration during hypoproteinemic states but significantly decreased soft tissue transvascular fluid flux.

Animals↗
PubMed1989

Effects of interleukin-2 on pulmonary and systemic transvascular fluid filtration.

Interleukin-2 (IL-2) therapy for patients with advanced cancer may be compromised by dose-limiting and life-threatening pulmonary and systemic edema. We studied the effects of bolus IL-2 infusion on lung and soft-tissue transvascular fluid and protein filtration in six sheep with chronic lung and soft-tissue lymphatic cannulation. Changes in lung (QL) and soft-tissue (QS) lymph flow were used as indicators of transvascular fluid filtration. A dose of 100,000 U/kg IL-2 was administered every 8 hours for 3 days. A significant increase (p less than or equal to 0.05) in both QL and QS was observed after each IL-2 infusion, with maximal flow occurring 2 to 3 hours after infusion. After 72 hours of IL-2 infusion, a fourfold maximal increase in QL occurred, which recovered to near-baseline values within 24 hours. Elevations in QL and QS were not associated with increases in pulmonary arterial or pulmonary arterial wedge pressures, but these elevations were associated with significant (p less than or equal to 0.05) increases in cardiac output (7.7 +/- 0.5 to 11.4 +/- 0.4 L/min) and a consistent decrease in systemic vascular resistance. A significant increase in lung lymph/plasma protein ratio (0.49 +/- 0.06 to 0.93 +/- 0.04 for albumin) revealed a marked increase in pulmonary microvascular porosity. This change, however, was not observed in the systemic microcirculation. Serum concentrations of tumor necrosis factor did not increase with the observed changes in pulmonary microvascular porosity. We conclude that IL-2 increases both pulmonary and systemic microvascular fluid flux. In addition, there is a marked increase in pulmonary, but not systemic, protein permeability that is not a consequence of changes mediated by tumor necrosis factor.

Animals↗
PubMed1988

Effects of iodine intake on thyroid secondary lysosomes after subtotal thyroidectomy.

This study tested the effects of different iodine intakes on thyroid ultrastructure and function in thyroid remnants after subtotal thyroidectomy (sub-tx). Removal of most of the thyroid gland causes an elevation of endogenous TSH, which chronically stimulates the residual tissue. Male Sprague-Dawley rats were divided into three groups; Low Iodine Group (LIG), Moderate Iodine Group (MIG), and High Iodine Group (HIG). There was no significant difference among total thyroid weights removed by sub-tx, but thyroid remnant weights and TSH levels were higher at death (6 weeks after sub-tx) in LIG than in MIG and HIG. Total specific activities of cathepsin D and of arylsulfatase A in the sedimentable and nonsedimentable subcellular fractions were at least 38% lower in LIG than in MIG and HIG. The ratio between relative follicular volume and colloid volume determined by morphometry was higher in LIG than in MIG and lower in HIG than in MIG. Ultrastructurally, the relative volume occupied by secondary lysosomes was higher in HIG than in MIG, whereas the number of secondary lysosomes was not higher in LIG than in controls. Autoradiographic studies with 125I revealed that a large part of the radioactivity was in thyroid cell secondary lysosomes in MIG and HIG when radioiodine was injected 3 weeks before death. It is concluded that after sub-tx, iodine 1) regulates the weight of thyroid remnants, perhaps only indirectly through TSH, 2) modulates the number of secondary lysosomes in thyroid cells, and 3) slows down the turnover of secondary lysosomes. An iodine-deficient regimen impedes the secondary lysosomes to increase. Because of these findings, we postulate that chronic TSH stimulation along with a possible toxic role of iodine after sub-tx could induce an accumulation of lysosomal bodies.

Animals↗
PubMed1988

Acute colonic ileus (pseudo-obstruction) in renal transplant recipients.

Colon complications are a potential source of serious morbidity to the immunosuppressed patient. Because of multiple predisposing factors, renal transplant patients are a high-risk group for the development of acute colonic pseudo-obstruction. During a recent 18-month period, 290 renal transplants (79 living, 211 cadaveric donors) were performed and prospectively analyzed for colonic dysmotility. A total of 34 episodes of acute colonic ileus (30 primary, 4 recurrent) occurred in 30 (10.3%) renal transplant recipients. Acute colonic ileus was more frequent after living-donor transplantation (19.0% vs. 7.1%, p = 0.006). Analysis of multiple variables revealed that the incidence of acute colonic ileus was directly related to mean cumulative prednisone dosage (p less than 0.05). Medical therapy (rapid steroid reduction, bowel rest) resulted in a 76.7% response, whereas 8 patients underwent colonoscopy because of progression to acute pseudo-obstruction. The success rate for colonoscopic decompression was 87.5%; in 1 patient cecal perforation developed after unsuccessful decompression. Overall, 33 of 34 (97.1%) episodes of acute colonic ileus were successfully treated. Steroid-induced ileus (pseudo-obstruction) is a potentially malignant early form of colonic dysmotility infrequently reported in transplant recipients. Successful management requires early clinical recognition, reduction in steroid dosage, bowel rest, and urgent colonoscopic decompression in select cases.

Adult↗
PubMed1988

A new technique and catheter design for assessing capacity and compliance characteristics of ileal reservoirs.

Ileal pouch reconstruction has become a preferred treatment for ulcerative colitis and familial polyposis in selected patients. Various pouch designs have been advocated with good functional results dependent upon preservation of excellent continence and a reasonable stool frequency pattern. Objective data are needed to recognize pouch designs that offer the best functional results. It is important to have a method of accurately measuring pouch volume and compliance characteristics of the pouch. We have described the construction and use of an inexpensive and easily assembled condom tipped catheter, which is useful for early and long term follow-up study of ileal pouch reconstructions.

Catheterization↗
PubMed1987

Management of chronic ulcerative colitis and rectovaginal fistula by simultaneous ileal pouch construction and fistula closure. Report of a case.

Persistent rectovaginal fistulas occurring with ulcerative colitis are unusual manifestations that complicate surgical or medical treatment of the primary disease. Prior to the development of ileal pouch procedures, many cases were traditionally managed with a total colectomy and permanent ileostomy. The authors are aware of no previous study using concurrent fistula repair combined with ileal pouch construction to manage this complex problem. The successful simultaneous repair of a chronic rectovaginal fistula with ileal pouch reconstruction in a patient with intractable ulcerative colitis is reported.

Adult↗
PubMed1987

Quadruple-loop (W) ileal pouch reconstruction after proctocolectomy: analysis and functional results.

This report analyzes experience with a modified four-limb W-shaped ileal pouch that has a larger initial capacity than do J- or S-shaped pouch designs. Fifteen patients (median age: 35 years) underwent W pouch reconstruction after proctocolectomy for ulcerative colitis and familial adenomatous polyposis. Follow-up on each patient averaged 14 months (range: 6 to 24 months). All procedures were performed without death and with minimal morbidity. Assessment of functional results showed 24-hour stool frequency (mean +/- SEM) decreasing from 6.0 +/- 0.39 initially to 4.8 +/- 0.43 at 1 year (p less than 0.005). Night evacuation decreased from 1.1 +/- 0.2 at 1 month after surgery to 0.25 +/- 0.12 at 1 year (p less than 0.025), with 10 of 15 patients having no nocturnal pouch evacuation. Continence was excellent in all patients with the exception of three of 15 patients who had occasional minimal nighttime seepage. Pouch volume determined at surgery by saline solution infusion was 200 +/- 21 ml. Pouch volume and compliance (pressure/volume) were measured before ileostomy closure and at 6 months after surgery via a special pressure-monitored balloon catheter. Maximal pouch volume increased from 190 +/- 21 ml (at time of ileostomy takedown) to 470 +/- 85 ml at 6 months. Ileal reservoir construction with a W pouch design resulted in a low 24-hour and nighttime stool frequency and excellent compliance and evacuation characteristics.

Adenomatous Polyposis Coli↗
PubMed1987

Modified quadruple-loop (W) ileal reservoir for restorative proctocolectomy.

Reconstructive ileal pouch procedures are well-accepted alternatives to a permanent ileostomy in select patients requiring proctocolectomy for ulcerative colitis and familial polyposis. Double-, triple-, and quadruple-loop and lateral isoperistaltic designs have been described; however, the ideal pouch capacity and configuration are still debatable. Evidence has been reported that improved functional results and lower stool frequency with less antidiarrheal medication can be achieved with larger volume reservoirs. We describe a new modification of a quadruple-loop pouch that has been successfully performed in 10 patients. This new approach to pouch construction produced excellent functional results 6 to 12 months after ileostomy takedown and was easier to construct and engage into the muscular cuff of the distal rectum than quadruple-loop pouches of equal length loops.

Adenomatous Polyposis Coli↗
PubMed1987

Diagnosis and treatment of genitofemoral and ilioinguinal entrapment neuralgia.

During the past 7 years 30 patients were diagnosed as having either ilioinguinal or genitofemoral entrapment neuralgia. A multidisciplinary approach (surgeon, neurologist, and anesthesiologist), as well as local blocks of the ilioinguinal nerve and/or paravertebral blocks of L-1 and L-2 (genitofemoral nerve), were essential to determine accurately which nerve was specifically involved. Fifteen of the 17 patients (88%) diagnosed as having ilioinguinal neuralgia after previous inguinal herniorrhaphy are pain free after resection of the entrapped portion of the nerve. Thirteen patients were diagnosed as having genitofemoral neuralgia after previous inguinal herniorrhaphy, blunt abdominal trauma, or other surgery. Neurectomy of the genitofemoral nerve proximal to the entrapment controlled the persistent pain in 10 of 13 (77%) of these patients. Ilioinguinal or genitofemoral nerve entrapment neuralgias are rare complications of surgery in the inguinal region. When accurately diagnosed, neurectomy of the specific nerve is highly successful in relieving severe pain and paresthesia without significant morbidity.

Adult↗
PubMed1986

Ectothermic philosophy of acid-base balance to prevent fibrillation during hypothermia.

In the ectotherms, or cold-blooded animals, carbon dioxide pressure decreases (PCO2) and pH increases as body temperature falls. This tends to increase coronary blood flow and prevent fibrillation. This concept was investigated in 181 consecutive patients undergoing open heart surgery of all types. In 121 cases, endothermic (warm-blooded) temperature-corrected normal values of pH, PCO2, and oxygen pressure were maintained during extracorporeal circulation as the perfusate temperature was lowered to 24 degrees C prior to aortic cross-clamping and administration of blood cardioplegia solution. In 49 patients (40%), ventricular fibrillation occurred prior to cross-clamping. In the other 60 consecutive cases, in which the ectothermic principle of cooling was applied, the PCO2 was allowed to decrease from 50 to 40 mm Hg and the non-temperature-corrected pH rose from 7.28 to 7.42. Fibrillation occurred in only 12 (20%) of these 60 patients.

Acid-Base Equilibrium↗
PubMed1986

Mirizzi syndrome simulating a tumor by ERC.

ERC was initially performed on a patient with right upper quadrant pain and jaundice. The filling defect in the CHD was felt to be a tumor. A correct preoperative diagnosis of Mirizzi's syndrome was made by CT.

Aged↗
PubMed1986

Hirschsprung's disease in young adults.

Hirschsprung's disease is rarely seen in the young adult, and presents unique problems in management because of the massive dilatation and hypertrophy that occur proximal to the aganglionic rectum or the rectosigmoid colon. The diagnosis, which may be suspected by barium enema, is confirmed by suction or full-thickness biopsy of the rectum that may be complemented by anal manometry. Based on our experience with eight patients, a two-stage surgical reconstruction is recommended, with a preliminary sigmoid colostomy through the normally innervated colon and an associated defunctionalized stoma constituting the initial operation. The distal colonic stoma permits cleansing of the caudal colon while the normally innervated proximal colon reverts to near normal caliber, usually within 2 to 6 months. This approach is in accord with the recommendation of Fairgrieve. Reconstruction using a Duhamel or Soave procedure has given good results. The Duhamel procedure seems preferable when a considerable discrepancy remains between the ganglionic and aganglionic segments of rectum.

Adolescent↗
PubMed1986

Rectal foreign bodies: case reports and a comprehensive review of the world's literature.

The surgical management of two patients presenting with incarcerated, apparently self-inserted foreign bodies is reported. The large volume of prior literature on this subject is reviewed, with tabulation of 182 previous cases by type and number of objects recovered and with a discussion of patients' age distribution, history, complications, and prognosis. Management problems addressed include history, differential diagnosis of reported pruritus ani, and handling of suspected assault. The variety of surgical techniques used to remove rectal foreign bodies transanally or after celiotomy is discussed. Vaginal foreign bodies and large bowel injuries due to fist fornication, colorectal instrumentation, pneumatic rupture, foreign body ingestion, impalement, and abdominal trauma are also discussed.

Adult↗
PubMed1985

Repair of subxiphoid incisional hernias with Marlex mesh after median sternotomy.

Median sternotomy is sometimes complicated by a bifid xiphoid process and an incisional (ventral) hernia in the subxiphoid region. Such hernias often recur after primary suture repair. We recently initiated the use of a polypropylene prosthetic mesh to primarily repair subxiphoid incisional hernias. This report details the results of using this material in 14 patients between January 1980 and December 1983. We also discuss the complex anatomy of the xiphoid region.

Adult↗