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Biomedical subjects

L C Carey

Publications and source records attributed to L C Carey.

At least 19 recordsLinked to original sources
PubMed1992

Colorectal trauma: primary repair or anastomosis with intracolonic bypass vs. ostomy.

This prospective, randomized, controlled study was undertaken to compare primary repair or anastomosis with intracolonic bypass vs. ostomy in severe colon and intraperitoneal rectal injury. Patients were randomized at surgery following confirmation of injury. Data collected included demographics, mechanism and location of injury, trauma score (TS), injury severity score (ISS), penetrating abdominal trauma index (PATI), complications, length of hospital stay, and hospital charges. Twenty-two patients were studied: 11 with intracolonic bypass and 11 controls. The experimental and control groups were statistically similar in demographics and mechanism of injury, severity of injury (TS = 13.8 vs. 12.8; ISS = 27.5 vs. 24.2; PATI = 40.5 vs. 35.0), and complication rate. Length of stay (12.2 days vs. 20.7 days) and charges $27,885 vs. $53,599) tended to be greater in controls, and the comparison did not include subsequent colostomy closure. This study supports intracolonic bypass as a safe alternative to ostomy in severe colon and intraperitoneal rectal trauma.

Adolescent↗
PubMed1992

Pancreaticoduodenectomy.

Few major abdominal operations have undergone the extent of dramatic change as that associated with pancreaticoduodenectomy in the last 20 years. The precipitous drop in the mortality rate most likely has a multifaceted explanation. Possibilities include the concentration of the operations at specialized centers, the improvement in the quality of critical care and anesthesia, and the improvement in the skill and experience of surgeons performing the procedure. Concomitant with the drop in the morality rate has been an increase in the resectability rate, along with the early encouraging evidence of improved long-term survival. However, many aspects of the technical portion of the procedure, particularly the pancreaticojejunostomy, need to be evaluated in prospective trials. The changes in the mortality and resectability rates make the operation more widely available to a larger number of patients, and the effectiveness of pancreaticoduodenectomy even for palliation is now well established.

Humans↗
PubMed1992

A new technique of laparoscopic cholangiography.

With the advent and rapid proliferation of laparoscopic cholecystectomy, numerous techniques and "tips" have been described. Intraoperative cholangiography during laparoscopic cholecystectomy can be tedious, frustrating, and time consuming. Described herein is a technique of intraoperative cholangiography during laparoscopic cholecystectomy which has proven to be easy, fast, and succinct. This method utilizes a rigid cholangiogram catheter which is placed into the peritoneal cavity through a small additional puncture site. This catheter is easily inserted into the cystic duct by extracorporeal manipulation. We suggest this method to surgeons who have shared our prior frustration with intraoperative cholangiography.

Catheterization↗
PubMed1992

Physician review improves hospital DRG reimbursement in injury.

This was a prospective study of all DRG reimbursed trauma patients discharged during an 11-month period. Initial DRGs were assigned by hospital coding specialists (HCS). A surgeon (SURG) subsequently reviewed each chart and assigned DRGs to maximize reimbursement. The data for 244 patients were: age = 36.5 years, Trauma Score (TS) = 13.8, Injury Severity Score (ISS) = 16.9, and length of stay (LOS) = 10.3 days. Total charges for the 244 patients were $4,261,208 with an initial HCS projected reimbursement of $1,687,963. The SURG review resulted in a total projected reimbursement of $1,956,476, an increase of $268,513 in revenue (p less than 0.001). Charges correlated strongly with LOS and ISS. The HCS-coded and SURG-coded reimbursements also correlated positively with LOS and ISS, but to a lesser extent. The SURG review of DRG assignment improved hospital reimbursement for the injured patients. However, this reimbursement fell well below hospital billings.

Abstracting and Indexing↗
PubMed1992

A simple technique for laparoscopic gastrostomy.

While endoscopically placed gastrostomy tubes are routinely simple, they are not always feasible. Endoscopic technique also does not uniformly secure the tube to the abdominal wall, which presents possible complications, including leakage, accidental early tube removal, intraperitoneal catheter migration and necrosis of the stomach or abdominal wall because of excessive traction. Presented herein is a technique that is rapid, simple and eliminates some of these potential complications. The technique is easily combined with other operative procedures, such as tracheostomy, is done under direct vision, can be performed quickly with intravenous sedation and local anesthetic and is a safe method of tube placement for enteral feeding or gastric decompression.

Gastrostomy↗
PubMed1991

Historical review of pancreaticoduodenectomy.

The performance of pancreaticoduodenectomy by Whipple in 1935 demonstrated that the operation was feasible technically and compatible with reasonable function after recovery. From the mid- to late 1940s until the last 10 years, the procedure was condemned by many because of its associated mortality and morbidity. For reasons that are not clear, the risk of pancreaticoduodenectomy in the last 10 years has fallen to less than 10% and in several centers, less than 5%. Postoperative complications have been reduced and blood transfusions are unnecessary in an increasing number of patients. Furthermore, a normal productive life without the need for medication and with no digestive disorder is expected. Seventy-one percent of patients are able to return to their preoperative occupation.

Chronic Disease↗
PubMed1991

Safety and efficacy of laparoscopic cholecystectomy. A prospective analysis of 100 initial patients.

Laparoscopic cholecystectomy quickly emerged as an alternative to open cholecystectomy. However its safety, efficacy, and morbidity have yet to be fully evaluated. During the first 6 months of 1990, we performed 100 consecutive laparoscopic cholecystectomies with no deaths and a morbidity rate of 8% (8 of 100 patients; 4 major, 4 minor). There were 81 women and 19 men, with a mean age of 46.1 years (range, 17 to 84 years). All patients had a preoperative history consistent with symptomatic biliary tract disease, and most had proved gallstones by sonography. This included four patients with acute cholecystitis. Mean operating time improved significantly from month 1 to month 6 (122 +/- 45.4 minutes versus 78.5 +/- 30 minutes, respectively), indicating a rapid learning curve. Mean hospital stay was 27.6 hours, reflecting a policy of overnight stay. Postoperative narcotic requirements were limited to oral or no medications in more than 70% of patients. A regular diet was tolerated by 83% of the patients by the morning following the procedure. Median time of return to full activity was 12.8 +/- 6.8 days after operation. In addition analysis of the hospital costs of these 100 cases demonstrates a modest cost advantage over standard open cholecystectomy (n = 58) (mean, $3620.25 +/- $1005.00 versus $4251.76 +/- $988.00). There was one minor bile duct injury requiring laparotomy and t-tube insertion, two postoperative bile collections, and one clinical diagnosis of a retained stone that passed spontaneously. Four patients required conversion to open cholecystectomy because of technical difficulties with the dissection. Although there is a significant learning curve, laparoscopic cholecystectomy is a safe and effective procedure that can be performed with minimal risk. Laparoscopic cholecystectomy should be performed by surgeons who are trained in biliary surgery and knowledgeable in biliary anatomy, and, as with all operations, it should be performed with meticulous attention to technique.

Adolescent↗
PubMed1991

Second-look surgery for colorectal cancer. The second time around.

Eighty-six colorectal cancer patients who entered the Radioimmunoguided Surgery (RIGS) protocol study were evaluated for 2-, 3-, 4-, and 5-year survival following second-look surgical procedures. Strict preoperative evaluation criteria eliminated patients with extra-abdominal tumor involvement. A saturated potassium iodide preparation was given before the intravenous administration of the B72.3 monoclonal antibody (1 mg) radiolabeled with 2 mCi of iodine-125 by the IODOGEN method. Precordial monitoring of the biologic clearance by the handheld, gamma-detecting probe (Neoprobe 1000 instrument) was conducted at weekly intervals until the average count was less than 20 counts in 2 seconds. Once the drug cleared from the blood, surgery was performed. The mean time interval between injection and operation was 24 days, with a range of 21 to 28 days and a median of 23 days. At surgery the abdomen was explored through the traditional methods of palpation and inspection, and the surgeon committed to a planned procedure. The abdomen was then re-explored with the handheld, gamma-detecting probe and the surgeon stated another intraoperative assessment. After using both traditional and RIGS detection methods, the surgeon stated whether his or her surgical plans changed because of the additional intraoperative information provided by the RIGS system. Fifty-three patients (62%) were deemed resectable by the traditional methods of palpation and inspection, but only 40 (47%) were specified as resectable by RIGS exploration. Two-, three-, four-, and five-year survival data could be gathered for each of the three groups: RIGS resectable (n = 40), traditional nonresectable (n = 33), and RIGS nonresectable (n = 13). At 2 years 95% of the resectable, 36% of the traditional nonresectable, and 53% of RIGS nonresectable patients survived. At 3 years 83%, 7%, and 30% of these patients survived, respectively. For the resectable patients, 74% survived at 4 years and 60% at 5 years, with no survivors from either nonresectable group. Use of the RIGS system increased accurate selection of resectable patients undergoing second-look surgery for recurrent colorectal cancer.

Antibodies, Monoclonal↗
PubMed1990

The use of endoscopy to treat bronchobiliary fistula caused by choledocholithiasis.

Bronchobiliary fistula is a rare disorder consisting of the formation of a passageway between the biliary ducts and the bronchial tree. We describe an 87-yr-old woman who had a bronchobiliary fistula secondary to obstruction caused by multiple common bile duct stones. The diagnosis was confirmed by the presence of bile in the sputum and transhepatic cholangiography. Successful stone extraction with balloon and basket techniques and endoscopic sphincterotomy decompressed the biliary tract and was followed by healing of the bronchobiliary fistula without surgical intervention, which has heretofore been considered the only successful means of treatment.

Aged↗
PubMed1990

Recurrent acute pancreatitis--rarely idiopathic: 1989 Du Pont lecture.

The majority (about 75%) of patients who suffer from acute pancreatitis do so as a consequence of gallstones or alcohol abuse. The other 25% of patients often present difficult diagnostic problems. Over several years the author has accumulated a series of patients with remedial causes of pancreatitis. They include a group of congenital conditions such as pancreas divisum, choledochal cysts and congenital abnormalities of the pancreatic ductal system. Patients who have had pancreatitis and who have an intact gallbladder often have stones that are difficult to identify. Repeated attacks of pancreatitis in the absence of any other apparent cause justifies cholecystectomy, which will often identify the cause so that recurrence can be prevented. A group of nonanatomic causes are also known. They include hyperlipidemia, drugs and toxins, certain systemic illnesses such as systemic lupus erythematosus, pregnancy, hypercalcemia, hereditary causes and occasionally cancer. In his lecture the author reviews the various etiologies of acute pancreatitis and describes an algorithm that can be used when the diagnosis is difficult.

Acute Disease↗
PubMed1989

Hepatic recovery after biliary decompression of experimental obstructive jaundice.

Obstructive jaundice was produced in 11 dogs by common bile duct ligation for 4 weeks, then biliary decompression was performed by bilioenteric anastomosis. Animals were regularly studied over the 2 months after decompression by the following methods: (1) serum biochemistry was monitored; (2) light microscopic changes in serial liver biopsies were graded; (3) the respiratory characteristics of isolated hepatic mitochondria, obtained by open liver biopsy, were studied using an oxygen micro-electrode system; (4) in vivo handling of an hepatobiliary imaging agent (diisopropyl iminodiacetic acid) was studied by dynamic liver scintiscanning. None of these liver assessments were normalized after 7 to 10 days of biliary decompression. Our study suggests that biliary decompression of patients with extrahepatic biliary obstruction requires long periods of time to enable major recovery of the abnormal liver function induced by biliary obstruction.

Anastomosis, Surgical↗
PubMed1989

Lymphocyte function in obstructive jaundice.

Sepsis is a major factor in the high mortality and morbidity after surgery for obstructive jaundice. Several studies have suggested that reticuloendothelial function is depressed, but changes in lymphocyte function are poorly understood. A model of obstructive jaundice has been produced by chronic common bile duct ligation in eight dogs. In vitro lymphocyte studies were performed both at 2 and 3 weeks duration of jaundice and compared with simultaneous healthy control subjects. Icteric animals showed no abnormality of natural killer cell function. Relative numbers of T and B lymphocytes and their subsets were unchanged. T lymphocyte responses to three mitogens were not significantly reduced in jaundiced animals. Serum immunoglobulin levels were unchanged compared to those before surgery apart from a significant rise in immunoglobulin A. No evidence of circulating immunosuppressive factors was found by mitogen testing on normal lymphocytes in the presence of pooled serum from jaundiced animals, normal serum, or normal serum with added bilirubin. Our study does not suggest that impairment of lymphocyte function contributes significantly to the dangers of sepsis in obstructive jaundice.

Animals↗
PubMed1989

DISIDA kinetics measure liver function in dogs.

We have investigated the ability of 99Tcm-disofenin (DISIDA) kinetics to measure liver function. Two approaches have been used: first, quantitative analysis of serial liver images, and second, clearance estimation from whole blood concentration-time data. Graded liver dysfunction was produced in 11 dogs over three months by common bile duct ligation and surgical relief of biliary obstruction one month later. The kinetic analysis of serial liver images showed clear abnormalities during biliary obstruction, with calculated rates of liver uptake falling in stages from 11.09 to 5.15 cts s-1 (p less than 0.001), and rates of elimination from the liver from 8.8 to 1.6 x 10(-4) cts s-1 (p less than 0.0001). These parameters paralleled the deterioration and recovery of liver function through the experimental period, and had not fully recovered 7 weeks after relief of biliary obstruction (10.5 and 6.2 x 10(-4) cts s-1 respectively). Serial blood sampling after injection of DISIDA permitted calculation of whole blood disposition rates (for hepatic clearance). Mean values fell from 256 to 67 ml min-1 with chronic biliary obstruction (p less than 0.001), and returned to almost normal (206 ml min-1) 10 days after surgical relief of biliary obstruction. It is clear that the gradual nature of recovering liver function was more sensitively identified by image analysis than serial blood data. Serial liver biopsies showed marked changes following biliary obstruction. These improved over a period of 7 weeks following its relief, when there was still considerable residual abnormality. This work supports the view that hepatic abnormalities caused by biliary obstruction do not recover quickly following its relief. DISIDA kinetics can quantitate both major and minor degrees of hepatic dysfunction, and may prove to be a valuable method to quantitative liver function.

Animals↗
PubMed1989

Splenectomy for hematologic disease.

Splenectomy has a major role in the treatment of hematologic diseases. Although it is rarely curative, splenectomy removes the site of the destruction or sequestration of erythrocytes, leukocytes, and platelets. Destruction occurs in such diseases as hemolytic anemia and ITP, whereas sequestration occurs as an idiopathic disease or secondary to a host of other diseases described above. Splenectomy is also indicated for symptomatic splenomegaly associated with leukemia, lymphoma, or myeloproliferative disorders. It is palliative, increasing the comfort of the patient by removing a massive spleen. Splenectomy also serves as a staging tool in lymphoma, Hodgkin's disease, and NHL, although it is much more beneficial in Hodgkin's disease, owing simply to stage at presentation. Splenectomy can be performed safely with minimal risk in most patients, but certain diseases carry increased risks of fatality and complications. Such diseases include leukemia, lymphoma, and myeloproliferative disorders, but even in these, splenectomy may be indicated in a select group of patients. The decision to perform splenectomy should therefore be made individually in these cases. Because it can be palliative in some cases, splenectomy can play a role in patient management, even though it may not alter survival.

Hematologic Diseases↗
PubMed1989

Gastrinoma: the predictive value of preoperative localization.

In the management of gastrinoma, a variety of preoperative tests for tumor localization are recommended. Their value in predicting surgical outcome is not well defined. We reviewed the preoperative investigation and operative outcome in 23 patients to assess the predictive value of localization before surgery. With results of laparotomy used as reference, the efficacy of computed tomography, angiography, ultrasonography, and magnetic resonance imaging, individually and combined for primary and metastatic disease, was determined. All investigative modalities were poor for the detection of primary gastrinomas, with individual sensitivities in the range of 20% to 29%. Their combined sensitivity was 53%, with a negative predictive value of only 38%. The detection of metastatic disease was better, with a combined accuracy of 83%. At laparotomy, tumor was identified in 19 of 23 (83%) patients. In 14 patients with negative preoperative workup, primary gastrinoma was found in 10 of 14 (71%) and resected for long-term cure in three of 14 (21%) patients. In all nine patients with positive preoperative test results, tumor was found and was resected for cure in four (44%) patients. In conclusion, preoperative localization of primary gastrinoma is unreliable, and a negative workup does not preclude cure. Therefore, despite the availability of effective palliative antiulcer therapy, all patients exclusive of those with multiple endocrine neoplasia, type I, or metastasis should undergo laparatomy with curative resection in mind.

Angiography↗
PubMed1987

Early surgical treatment of gastrinoma.

Medical treatment of the Zollinger-Ellison syndrome has been generally accepted because of the proven efficacy of the histamine (H2)-receptor antagonists in achieving symptomatic relief, and because of early reports indicating that few, if any, gastrinomas were resectable for cure. Gastrin radioimmunoassay (RIA) has made earlier and more certain diagnosis possible, and therefore reevaluation of the surgical management of gastrinomas is necessary. Experience with 60 gastrinoma patients is reported. Comparison between the pregastrin RIA years (before 1970) and post-gastrin RIA years was made to determine whether there was evidence to support the continuation of medical treatment without attempts to resect the gastrinoma. Twenty-five cases were diagnosed in the pre-RIA years. Age at diagnosis ranged from 17 to 68 years (median, 45 years). All patients were operated on. Metastases were found in 56 percent. No tumor was identified in 8 percent. Tumor was resected for "cure" (normal fasting gastrin levels for two years postoperatively) in one patient. Seventeen patients have died, and tumor was the cause of death in 70 percent. The five-year survival rate was 44 percent; the 10-year survival rate was 40 percent. Thirty-five cases were diagnosed after 1970. Age at diagnosis ranged from 39 to 61 years (median, 46 years). Thirty patients were operated on. Metastases were identified in 23 percent and no tumor was found in 17 percent. Tumor was resected for "cure" in 30 percent of patients. Seven patients have died and tumor caused death in 42 percent. The five-year survival rate was 82 percent; the 10-year rate was 64 percent. Advances in diagnosis and surgical technique since 1970 have made early operative treatment applicable in patients with gastrinoma. Because death in most cases is caused by progression of the tumor, an aggressive surgical approach to resect the tumor is advised soon after the diagnosis of Zollinger-Ellison syndrome is established.

Duodenal Neoplasms↗