Biomedical subjects

K W Sharp

Publications and source records attributed to K W Sharp.

At least 37 records · Page 2Linked to original sources

PubMed1994

Incidence of inguinal hernias diagnosed during laparoscopy.

This prospective study was done to identify the incidence of asymptomatic hernias diagnosed during laparoscopic surgery. Previously unidentified inguinal hernias were discovered in 13 of 100 consecutive patients undergoing laparoscopic procedures (13%). Nine of the patients were male, four were female. The average age was 43.3 years. Four defects were direct and nine were indirect (patent processus vaginalis). Eleven defects were small (< 3 cm) but two were large (> 3 cm). All four direct defects occurred in male patients. We conclude that asymptomatic defects are surprisingly common in our surgical population (13%) and that laparoscopic examination of the pelvis is a sensitive technique for identifying these defects. To date, no patient with laparoscopically diagnosed hernia has had symptoms or complications related to the hernia. We recommend that the surgeon should note in the medical record the presence of a defect, but not proceed with prophylactic repair of asymptomatic defects.

Adult↗

PubMed1993

The staged celiotomy for trauma. Issues in unpacking and reconstruction.

OBJECTIVE: This article describes the important clinical events and decisions surrounding the reconstruction/unpacking portion of the staged celiotomy for trauma. METHODS: Of 13,817 consecutive trauma admissions, 1175 received trauma celiotomies. Of these, 107 patients (9.1%) underwent staged celiotomy with abdominal packing. The authors examined medical records to identify and characterize: (1) indications and timing of reconstruction, (2) criteria for emergency return to the operating room, (3) complications after reconstruction, and (4) abdominal compartment syndrome (ACS). RESULTS: Fifty-eight patients (54.2%) survived to reconstruction, 43 (74.1%) survived to discharge; 9 patients (15.5%) were returned to the operating room for bleeding; 13 patients required multiple packing procedures. There were 117 complications; 8 patients had positive blood cultures, abdominal abscesses developed in 6 patients, and ACS developed in 16 patients. CONCLUSIONS: 1. Reconstruction should occur after temperature, coagulopathy, and acidosis are corrected, usually within 36 hours after the damage control procedure. 2. Emergent reoperation should occur in any normothermic patient with unabated bleeding (greater than 2 U packed cells/hr). 3. ACS occurs in 15% of patients and is characterized by high peak inspiratory pressure, CO2 retention, and oliguria. Lethal reperfusion syndrome is common but preventable.

Abdomen↗

PubMed1993

Improved survival with neoadjuvant therapy and resection for adenocarcinoma of the esophagus.

OBJECTIVE: This study sought to determine the impact of preoperative chemotherapy and radiation therapy (neoadjuvant therapy) followed by resection in patients with adenocarcinoma of the esophagus. SUMMARY BACKGROUND DATA: Long-term survival in patients with carcinoma of the esophagus has been poor. An increase in the incidence of adenocarcinoma of the esophagus has been reported recently. METHODS: Fifty-eight patients with biopsy-proven adenocarcinoma of the esophagus treated at this institution from January 1951 through February 1993 were studied. Since 1989, 24 patients were entered prospectively into a multimodality treatment protocol consisting of preoperative cisplatin, 5-fluorouracil (5-FU), and leucovorin with or without etoposide, and concomitant mediastinal radiation (30 Gy). Patients were re-evaluated and offered resection. RESULTS: There were no deaths related to neoadjuvant therapy and toxicity was minimal. Before multimodality therapy was used, the operative mortality rate was 19% (3 of 16 patients). With multimodality therapy, there have been no operative deaths (0 of 23 patients). The median survival time in patients treated before multimodality therapy was 8 months and has yet to be reached for those treated with the neoadjuvant regimen (> 26 months, p < 0.0001). The actuarial survival rate at 24 months was 15% before multimodality therapy and 76% with multimodality therapy. No difference in survival was noted in neoadjuvant protocols with or without etoposide (p = 0.827). CONCLUSIONS: Multimodality therapy with preoperative chemotherapy and radiation therapy followed by resection appears to offer a survival advantage to patients with adenocarcinoma of the esophagus.

Actuarial Analysis↗

PubMed1992

Abdominal packing for surgically uncontrollable hemorrhage.

Planned intra-abdominal packing for surgically uncontrollable hemorrhage from liver and retroperitoneal injuries exacerbated by hypothermia, acidosis, and coagulopathy regained popularity over the past decade. The authors reviewed 39 patients injured between August 1985 and September 1990; 31 packed for liver injuries, eight for nonliver injuries. The overall mortality rate was 44% (17/39); 9 (23%) exsanguinated, 3 (8%) died of head injuries, 3 (8%) of multisystem organ failure, 2 (5%) of late complications. The mean age was 33.9 +/- 16.2 (range, 16 to 79); there were 26 men and 13 women. Relaparotomy for pack removal was performed 2.0 +/- 1.1 days (range, 1 to 7) after initial operation. The authors identified intraoperative risk factors of pH less than or equal to 7.18, temperature less than or equal to 33 C, prothrombin time greater than or equal to 16, partial thromboplastin time greater than or equal to 50, and transfusion of 10 units or more of blood as highly predictive of outcome. Patients with four to five risk factors (n = 3) had a 100% mortality rate (p less than 0.04); two to three risk factors (n = 12), 83% mortality rate (p less than 0.003), compared with zero to one risk factors (n = 24), 18% mortality rate. Complications developed in six of 22 survivors (27%): 5 abdominal abscesses (23%), 2 wound dehiscences (9%), and 2 enterocutaneous fistulae (9%). Intra-abdominal packing will not stop all bleeding; 23% of the patients exsanguinated. In 77%, packing helped achieve hemostasis we believed was not otherwise possible. Packing may be done to prevent the development of acidosis, hypothermia, and coagulopathy or may be done early in the treatment of cold, acidotic patients rather than massive transfusion in the face of surgically uncorrectable bleeding.

Acidosis↗

PubMed1992

Treatment priorities in patients with traumatic rupture of the thoracic aorta.

Autopsy studies reveal that 90 percent of patients with traumatic rupture of the thoracic aorta (TRTA) die at the scene of the accident and 25 percent of those reaching the hospital do not survive their injuries. Treatment priorities in patients with TRTA and associated life-threatening head and intra-abdominal injuries have not been adequately studied. The authors reviewed their experience with 57 consecutive patients sustaining TRTA to establish treatment priorities in these multiply injured patients. The mean age of the population was 35 years (43 men, 14 women). Hospital mortality was 24 percent; the most common cause of death was hemorrhage. Fully 95 percent of the patients had associated injuries requiring operative intervention. Abdominal injuries requiring laparotomy were present in 20 patients (35%): 14 splenic injuries, 8 liver injuries, 3 pancreatic injuries, and 3 mesenteric lacerations. Twenty-eight patients (49%) had orthopaedic injuries requiring operative fixation. Maxillofacial injuries requiring surgical repair occurred in 20 patients (35%). Fifteen patients (26%) sustained significant closed head injuries, but only 1 required craniotomy for hemorrhage. Nine hemodynamically unstable patients with intra-abdominal hemorrhage underwent immediate laparotomy for control of bleeding followed by aortography and aortic repair (2 deaths, 22%). Seven hemodynamically stable patients had aortography followed by laparotomy for control of intra-abdominal hemorrhage with subsequent thoracotomy (1 death, 14%). Thirty stable patients underwent aortography followed by immediate thoracotomy; 22 required no further procedures, while 8 required an additional operation (7 death, 23%).(ABSTRACT TRUNCATED AT 250 WORDS)

Accidents, Traffic↗

PubMed1991

Laparoscopic cholecystectomy in the pediatric patient.

Since June 1990, five girls and one boy have been evaluated for biliary colic. Gallstones were documented by sonography. Two girls, ages 8 and 14 years, had hereditary spherocytosis, and a 9-year-old boy had sickle cell disease. The other three girls, ages 13, 13, and 15 years, developed cholelithiasis and biliary colic without a history of hematological disease. Three children weighed less than 90 lb, with the smallest weighing 45 lb. All patients underwent laparoscopic cholecystectomy without complications. Operative cholangiography was performed in five of the six children. The KTP-532 laser was used for dissection of the gallbladder from the liver bed in two patients, and electrocautery was used in the remaining four. The average operating time was 1 hour 45 minutes. This is a report of the use of laparoscopic cholecystectomy in pediatric patients. The advantages of its use include a shorter hospitalization, decreased postoperative discomfort, and a much shorter interval between the surgical procedure and return to normal activities such as school and play. At this time, it is recommended for those children without complications from their cholelithiasis such as common duct obstruction and gallstone pancreatitis.

Adolescent↗

PubMed1991

Improving palliation in pancreatic cancer: intraoperative celiac plexus block for pain relief.

Most patients with pancreatic carcinoma are not curable. Surgical palliation of obstructive jaundice and gastric outlet obstruction leaves many patients with severe pain from pancreatic carcinoma. Anesthesiologists have drawn increasing attention to the successful use of postoperative percutaneous celiac plexus block for the treatment of pancreatic pain. Ironically, little attention has been paid to celiac plexus block during laparotomy. We reviewed the cases of 12 patients with pancreatic carcinoma and severe abdominal pain who were treated surgically. All patients had operative celiac plexus block with absolute alcohol at the time of exploratory laparotomy for biliary bypass, gastroenterostomy, or tumor biopsy. Complete postoperative pain relief was obtained in 10 of the 12 patients; two had only partial relief. No operative complications were related to celiac plexus block; one patient died postoperatively of pneumonia. Average postoperative hospital stay was 13 days and average postoperative survival was 3 1/2 months. Most patients had excellent pain relief for at least 2 months or until death. Because most patients treated surgically for pancreatic carcinoma are receiving only palliation with biliary bypass or gastroenterostomy, surgeons should pay increased attention to pain relief. Operative celiac plexus block is easy, safe, and highly effective in relieving the agonizing pain of pancreatic carcinoma.

Adult↗

PubMed1990

Changes in gallbladder volume do not affect cystic duct resistance.

To our knowledge, the relationship between gallbladder volume and cystic duct function has not been studied. We hypothesized that changes in gallbladder volume would influence cystic duct resistance. The effect of gallbladder volume changes on cystic duct resistance to both prograde (emptying) and retrograde (filling) steady-state flow was tested in 12 dogs under basal cholecystokinin-stimulated conditions utilizing a multiport catheter with a highly compliant balloon placed within the gallbladder fundus. Gallbladder volume was regulated by varying balloon volume from empty to just beyond physiologic distention. Cystic duct resistance was not affected by balloon volume under basal or stimulated conditions or by the direction of perfusate flow. This study demonstrated no relationship between gallbladder volume and cystic duct resistance and did not demonstrate a cystic duct sphincter mechanism at physiologic gallbladder volumes.

Animals↗

PubMed1990

Diverticular disease of the jejunum and its complications.

Jejunal diverticulosis is an uncommon, acquired condition that has been encountered recently in four patients. These cases (two patients with diverticulitis, one patient with chronic abdominal pain, and one patient incidentally discovered at laparotomy for colonic diverticulitis) are reported. Acute complications of jejunal diverticulosis include diverticulitis, bleeding, and intestinal obstruction. Chronic complications include intractable abdominal pain, malabsorption, and intestinal pseudo-obstruction. Up to 15 per cent of patients with jejunal diverticulosis may require small-bowel resection for treatment of these acute or chronic complications. The clinical significance, proper diagnostic evaluation, and treatment of jejunal diverticular disease are reviewed.

Abdominal Pain↗

PubMed1990

Local resection of tumors of the ampulla of Vater.

Local resection of an ampullary tumor with reimplantation of the pancreatic and bile ducts was first described by William S. Halsted in 1899. Technical hazard and unsuitability in malignant ampullary tumors have unfortunately led to a disregard for this operation that is unwarranted. Radical pancreaticoduodenectomy is now the most common method of resecting benign and malignant ampullary tumors. Experience was gained with two high-risk patients with benign adenomatous polyps obstructing the ampulla of Vater. Their medical unsuitability for radical pancreaticoduodenectomy led us to revive the procedure of wide local excision of these tumors with reimplantation of the pancreatic and bile ducts. Operative time and blood loss were substantially less than radical resection and postoperative recoveries were relatively uncomplicated. Radical resection of benign ampullary tumors may be appropriate for good-risk patients in whom the risk of local recurrence outweighs the operative risk. We suggest that local resection of benign ampullary tumors is the procedure of choice in high-risk patients and that it be considered in palliation of limited local malignancies of the ampulla in high-risk patients.

Adenocarcinoma, Papillary↗

PubMed1989

Common bile duct healing. Do different absorbable sutures affect stricture formation and tensile strength?

Few basic investigations have addressed the problem of common bile duct strictures. We systematically investigated the healing canine end-to-end choledochal anastomosis and tested the hypothesis that common bile duct anastomoses sutured with monofilament polyglyconate absorbable suture would heal with less stricture formation and greater tensile strength than those sutured with braided polyglactin 910 and chromic catgut sutures. Seventy-six canines, randomized to control vs sutured groups, underwent either mobilization (controls) or transection of the mid-common bile duct and were allowed to heal 5, 10, 15, or 50 days postoperatively before sacrifice. The type of absorbable suture used to construct a common bile duct anastomosis was found to have no major effect on anastomotic strictures nor on anastomotic breaking strength. Polyglyconate suture caused significantly less perianastomotic inflammation than did chromic suture, with polyglactin 910 sutures evoking an intermediate inflammatory response. Surgeons may safely choose sutures for biliary procedures based on the clinical circumstances and personal preference.

Anastomosis, Surgical↗

PubMed1989

Tumor seeding from percutaneous biliary catheters.

Percutaneous transhepatic biliary decompression has been used since 1973 as a preoperative surgical adjunct in patients with obstructive jaundice. Tumor seeding along the catheter tract is an unusual complication but it occurred recently in one of our patients who had preoperative biliary drainage for four days. Four months after his pancreaticoduodenectomy, a 2-cm nodule developed at the catheter exit site. This nodule was a metastatic focus of adenocarcinoma similar to his pancreatic tumor. He died 1 month later and at autopsy was found to have numerous metastases along the catheter tract. A review of the world literature found 17 other patients with this complication. Thirteen of the 18 total patients had catheters placed for palliation, while 5 patients underwent preoperative drainage before definitive procedures, and 4 of these patients had undergone "curative" resections. Nine of the 18 patients had biliary obstruction from cholangiocarcinoma, while seven patients had primary pancreatic carcinoma. Positioning of the catheter tip above the obstructing tumor and maintaining the catheter for only a short duration before operation (mean 8 days for resected patients, range 2 to 16 days) did not protect against catheter-related tumor seeding. Patients with suspected malignant obstruction of the biliary tract who may have resectable tumors should not undergo routine preoperative biliary decompression. If, on exploration, the tumor is found to be unresectable, then a palliative bypass may be performed.

Adenocarcinoma↗

PubMed1989

Recent experience with benign biliary strictures.

The management of benign biliary strictures continues to represent one of the most difficult problems in the practice of general surgery. Twenty-eight consecutive patients with benign strictures treated between 1972 and 1987 are reviewed in this report. Stricture etiology was iatrogenic in 13 patients, pancreatitic in 11, idiopathic in three, and traumatic in one. The authors performed 27 operations and three percutaneous transhepatic balloon dilatations in the treatment of these patients. Operative morbidity was 18 per cent; there were no operative deaths. Treatment was successful in 23 of 28 patients with a mean followup of four years, and four of the five patients with initially unsuccessful results have undergone successful remedial operations. Roux-en-Y biliary enteric diversion procedures have been most successful in these patients: seven patients with Roux-en-Y choledochojejunostomy without recurrence (mean followup of 62 months) and eight patients with Roux-en-Y hepaticojejunostomy with a success rate of 87.5 per cent (mean followup of 50 months). Two patients underwent three percutaneous transhepatic balloon dilatations; one has had a good result with short followup and the other failed on two occasions and has required a remedial operation. Benign biliary strictures have multiple etiologies. Therapeutic approaches, which now include nonoperative procedures, must be tailored to the needs of individual patients. The potential for recurrence is always present. Longterm followup remains essential in the management of patients with this disorder.

Adult↗

PubMed1989

Pancreatoduodenectomy with pyloric preservation for carcinoma of the pancreas: a cautionary note.

Radical pancreatoduodenectomy for treatment of pancreatic carcinoma has been the surgical standard of care for the past four decades. The recent popularization of pylorus-sparing pancreatoduodenectomy to treat benign pancreatic disease, because of its decreased morbidity and long-term nutritional consequences, has led to the use of this procedure in cases of pancreatic carcinoma. We report recent experience with three patients with pancreatic carcinoma in whom pyloric preservation would have compromised the potential chance for curative resection or compromised palliation because of occult spread of tumor to a region not resected with this new operative approach. Two patients had proximal, microscopic intramural spread of pancreatic adenocarcinoma within the duodenum or antrum--a mode of spread not previously reported with pancreatic carcinoma. Both patients had no other evidence of metastatic involvement, and both would have had positive surgical margins in a pylorus-sparing pancreatoduodenectomy. A third case demonstrates a true submucosal recurrence of pancreatic carcinoma after a pylorus-sparing pancreatoduodenectomy. It is debatable that any case demonstrating intramural spread within the duodenum could be cured with a standard Whipple resection as this may well represent another sign of incurability, like lymphatic or perineural spread, but it is clearly a major potential obstacle to palliation if submucosal recurrences occur as a result of the use of the pylorus-sparing pancreatoduodenectomy in cases of pancreatic cancer. The use of pylorus-sparing pancreatoduodenectomy in resectable pancreatic cancers must be viewed skeptically at this time.

Adenocarcinoma↗

PubMed1988

Acute cholecystitis.

Acute cholecystitis is a common cause of the acute abdomen. The diagnosis has been distinctly improved with the development of ultrasonography and hepatobiliary scanning over the past 20 years. The treatment is cholecystectomy, with early as opposed to delayed operation gaining increasing popularity nationwide. Acute acalculous cholecystitis and emphysematous cholecystitis are special features of acute cholecystitis occurring in more complicated cases and requiring diligence in diagnosis and great care in treatment.

Abdomen, Acute↗

PubMed1988

Is total pelvic exenteration reasonable primary treatment for rectal carcinoma?

Total pelvic exeneration (TPE) is reasonable primary surgical therapy in select patients with large bulky locally invasive rectal cancers that can be removed en bloc. Many do not have either nodal or distant metastasis. Furthermore, TPE can be curative and often is palliative for similar lesions that are recurrent or nonresponsive to radiation therapy. Operative mortality rates should be under 10% and can be under 5% for primary cases. Although improvement in preoperative management and operative technique, especially with urinary conduits and postoperative care is clear, both early and late complications are significant. Unfortunately, preoperative identification of those patients requiring TPE rather than abdominoperineal or low anterior resection remains poor. Furthermore, recent improvements in techniques for pelvic slings to prevent small bowel entrapment and protection from irradiation or myocutaneous flaps to obliterate the massive dead space are not yet clearly established as preventors of either early or later complications.

Carcinoma↗

PubMed1988

Do multi-lumen catheters increase central venous catheter sepsis compared to single-lumen catheters?

Triple-lumen catheters (TLC) are now routinely used in critically ill and multiply injured patients who require multi-port central venous access. An apparent rise in catheter contamination and catheter-related sepsis (CRS) occurred in patients receiving total parenteral nutrition (TPN) through a TLC as opposed to a single-lumen catheter (SLC). A prospective study was performed to determine rates of catheter contamination and CRS in multiple trauma and general surgical-medical patients who received TPN through TLC's and SLC's. Three hundred seven TLC's and 68 SLC's were placed in 234 patients during a 12-month period. There was no statistically significant difference in the rate of contamination or CRS between the two groups although there was a trend toward increased CRS and contamination in the TLC group. TLC's may be used for short-term administration of TPN without significant increase in catheter contamination or CRS.

Bacterial Infections↗

PubMed1988

Efficacy of computerized tomography in the preoperative staging of pancreatic carcinoma.

The increasing use of nonoperative methods for the diagnosis and palliative treatment of pancreatic cancer has placed greater emphasis on computerized tomography (CT) in staging of this malignancy. The present study was done to review our experience with CT in staging pancreatic cancer, specifically its efficacy in predicting lesions amenable to curative versus noncurative surgical treatment. Sixty six consecutive patients with pancreatic cancer who were considered potential candidates for surgical resection and who had preoperative CT scans over the 4-year period from 1982 through 1986 were studied. Preoperative CT scans were reviewed by a radiologist without knowledge of patients' surgical management. CT criteria for unresectable disease include hepatic and distant metastasis as well as evidence of locally advanced disease, including peripancreatic fascial extension, extension of tumor to locally contiguous structures, vascular encasement/invasion, and local lymphadenopathy. CT predicted resectability with a sensitivity of 75 per cent and a positive predictive value of 38 per cent. Unresectability was predicted with a sensitivity of 72 per cent and positive predictive value of 93 per cent. CT incorrectly predicted unresectable disease in three patients who had a curative resection. CT was most reliable when it predicted unresectability due to the presence of hepatic and/or distant metastasis. CT predicted unresectability with least sensitivity using criteria for locally advanced disease. Therapeutic decisions for nonoperative management of patients with pancreatic cancer based upon CT predictions of unresectable disease, especially predictions of unresectability solely on the basis of locally advanced disease, can not be recommended at this time.

Adenocarcinoma↗