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L H Blumgart

Publications and source records attributed to L H Blumgart.

At least 19 recordsLinked to original sources
PubMed1992

[Percutaneous transhepatic inserted self-expanding metal endoprosthesis in the palliative treatment of malignant obstructive jaundice].

Prospective studies comparing biliary-enteric bypass with implantation of endoprostheses in palliation of malignant obstructive jaundice showed no significant difference. A new self-expandable metal endoprosthesis was introduced to ameliorate the results in terms of early complication and occlusion rate. Between December 1988 and April 1991 we treated 35 patients (32 with malignant obstructive jaundice) by 50 self-expandable endoprostheses. The implantation was successful in 96% of patients. The early complication rate was 37% and the 30-day mortality 14%. In 89% of the patients relief of jaundice after 3 months was found. Recurrent jaundice and cholangitis occurred in 39%, whereas reoperation was necessary in 25%. 16 of 26 patients (61%) with malignant obstructive jaundice where alive after an average of 7.5 months. We found no advantage of the self-expandable endoprostheses compared with conventional plastic stents. Implantation of a self-expandable metal endoprosthesis may be an alternative to surgical bypass in selected cases. It would be interesting to evaluate the endoscopic route of insertion and to compare the results with palliative surgery in randomized studies.

Aged↗
PubMed1992

Clinical experience with adult polycystic liver disease.

Adult polycystic liver disease is characterized by multiple diffuse cystic lesions of the liver, usually in association with polycystic kidney disease. Rarely, significant liver disease will produce enough symptoms to call for surgical attention. Symptoms range from simple compression to fatal liver failure. Treatment of seven patients (six women) with symptomatic polycystic liver disease over 18 months is reported. Rapidly progressing liver failure and sepsis from infected ascites following puncture developed in one patient and precluded surgery. Another presented with an acute abdomen and anaemia from liver cyst bleeding and was treated conservatively. Five patients with massive hepatomegaly and compression symptoms underwent fenestration and resection to debulk the cystic liver mass. No intra-abdominal drains were used after operation and there were no hospital deaths. One patient developed a bile leak which was managed by percutaneous drainage. Clinical approach, complications and treatment options in adult polycystic liver disease are reviewed.

Adult↗
PubMed1992

Prospective study in adults of splenic preservation after traumatic rupture.

Seventy-five adults with splenic injury were evaluated prospectively over 45 months to examine the possibility of splenic preservation. Haemodynamically unstable patients underwent surgery with the intent of splenic preservation. Stable patients received non-operative treatment regardless of the grade of splenic injury determined by ultrasonography and computed tomography. Thirty-seven patients required splenectomy and in 38 the organ was preserved (20 operative preservation, 18 non-operative treatment). Of 22 patients initially receiving non-operative treatment, there were four secondary haemorrhages after 7, 7, 10 and 13 days making surgery necessary. Three of these patients underwent splenectomy and in one the spleen was preserved by partial resection. After splenectomy four patients required reoperation because of rebleeding or for evacuation of a haematoma. Patients who had undergone splenectomy had a significantly increased infection rate (P < 0.005) compared with those in whom the spleen was preserved, even when patients were matched with respect to multiple trauma using the Injury Severity Score (P < 0.01).

Adolescent↗
PubMed1992

Enucleation of giant hemangiomas of the liver. Technical and pathologic aspects of a neglected procedure.

Cavernous hemangiomas are the most common benign tumors of the liver. Giant cavernous hemangiomas, defined as those larger than 4 cm in diameter, can reach enormous proportions. Newer imaging modalities, although often demonstrating characteristic features that strongly suggest the diagnosis, should not be augmented by biopsy because of the risk of hemorrhage. Elective surgical resection may be indicated for symptomatic giant lesions and for those with an atypical appearance where the diagnosis is in doubt. Between October 1986 and May 1991, we treated 10 patients with giant hemangiomas by enucleation or enucleation plus resection. Median operative blood loss was 800 mL (range, 200 to 3000 mL). One patient required reoperation for control of postoperative hemorrhage. Detailed pathologic examination has demonstrated an interface between hemangiomas and the normal liver tissue that allows enucleation. Enucleation is an underused procedure that if carefully performed allows resection of giant hemangiomas with a reduced blood loss and the preservation of virtually all normal hepatic parenchyma.

Adult↗
PubMed1992

Fatal ascaris pancreatitis: an uncommon problem in the west.

Gastrointestinal parasites, although an uncommon cause of biliary and pancreatic problems in western medicine, can produce fatal complications. A Swiss patient presented with acute pancreatitis, with no evidence of gall stones or history of alcohol abuse. He died after a short fulminant illness. At necropsy, an Ascaris lumbracoides was found impacted within the ampulla of Vater and serves as a reminder that non-indigenous causes of biliary tract obstruction should not be overlooked.

Aged↗
PubMed1992

Radiation stricture of the biliary ducts: an emerging new entity?

Two patients with stricture of the extrahepatic biliary tree are described. Both patients presented with a clinical picture of obstructive jaundice one to two years following radiotherapy for a malignant condition. As no recurrent tumour was detected in either of the patients the strictures were considered to be the result of radiation therapy. Bilio-enteric decompression was performed in both patients who are well at follow up one and ten years after the procedure.

Adult↗
PubMed1992

Staging of hilar cholangiocarcinoma by ultrasound and duplex sonography: a comparison with angiography and operative findings.

The pre-operative radiological assessment of proximal bile duct tumours is clinically important as resection may be limited by tumour extension along the bile ducts, into hepatic parenchyma or the adjacent vascular structures. Demonstration of the extent of biliary and vascular involvement can direct additional investigations and definitive treatment. 22 patients with hilar cholangiocarcinoma were studied pre-operatively by conventional ultrasound (US) and duplex sonography (DS). The extent of tumour infiltration and vascular involvement was compared with arteriography and operative findings. Bile duct dilatation and the level of obstruction was documented by US in 22 (100%), and the tumour was shown by US in 19 (86%). In these 19 patients, the extent of extraductal extension compared with operative findings was correct in 13, underestimated in two, and in four infiltration was massed. Vascular patency or involvement was correctly determined by DS in 19 (86%), and by arteriography in 18 (82%). In two of the three incorrect DS interpretations, lobar atrophy and contralateral hypertrophy distorted the hilar anatomy. US with DS is valuable in the pre-operative staging of proximal bile duct tumours in predicting ductal and vascular involvement.

Adenoma, Bile Duct↗
PubMed1992

Current management of hilar cholangiocarcinoma.

The goal in the treatment of hilar cholangiocarcinoma is the relief of biliary obstruction with the quality survival. The choice of therapy for an individual patient requires complete preoperative staging to determine the resectability. This is best accomplished in a multidisciplinary setting with radiologists, gastroenterologists and surgeons participating in the diagnostic and therapeutic strategies. Operative removal of the tumor can be performed with low mortality and, when possible, provides the longest palliation and offers potential for cure. For tumors found at operation to be unresectable, biliary enteric bypass provides a durable method of palliation. The relative merits of the newer methods of radiologic stenting are encouraging, but further study will require prospective trials in comparison to operative biliary enteric bypass.

Adenoma, Bile Duct↗
PubMed1992

[Experimental atrophy/hypertrophy complex of the liver after portal and/or biliary ligation in the rat].

Patients with lobar or segmental, benign or malignant strictures of the biliary tree (with or without impairment of the portal blood flow) show a considerable atrophy of the involved area of the liver with a compensatory hypertrophy/hyperplasia of the remaining non affected liver. To investigate the importance of the biliary and portal obstruction for the development of this process, we used a rat model, with selective biliary and/or portal ligation of the anterior liver lobes (two thirds of the liver mass). Weight measurements, morphometry, functional scintigraphy (Hepatoiodida-scan) and blood enzyme analyses were done immediately postoperatively, at 30 hours and 4, 8 and 28 days after the operation. The major findings were: 1. 28 days after biliary and/or portal ligation there was no difference between the body weight of the four groups, all ligated animals having compensated for an initial greater percentage body-weight loss. 2. Total liver weight remained constant, while atrophy and hypertrophy/hyperplasia occurred although a progressive derangement of liver morphology was observed during that time. 3. A severe atrophy-hypertrophy-complex (AHC) developed after selective portal ligation, which in our experiment did not appear after selective biliary ligation. 4. Morphometrical changes after selective biliary ligation were reversible, whereas in liver lobes with selective portal ligation a progressive parenchymal destruction and involution with subsequent impairment of hepatic function of the concerned lobe was observed.

Animals↗
PubMed1992

[Prospective study of the early postoperative course of splenic rupture: spleen preservation versus splenectomy].

The haematological and immunological changes after splenectomy have been the subject of intensive research in recent years. As a consequence there has been a clear trend towards splenic salvage. Due to the availability of improved diagnostic investigations (sonography, CT) nonoperative treatment with close observation has become increasingly important in adults. 75 patients with documented splenic injury were prospectively evaluated over a 45-month period with an emphasis upon splenic preservation. Unstable patients had operative exploration with attempt at splenorrhaphy or partial splenic resection. Stable patients were managed nonoperatively, regardless of the degree of splenic injury as determined by sonography and/or computed tomography. In 38 patients the spleen was preserved by operative preservation in 20 and nonoperative treatment in 18 patients. 37 patients required splenectomy. Four patients were managed initially by nonoperative treatment, but required exploration for secondary rupture at 7, 7, 10 and 13 days. Delayed splenectomy was performed in three patients and one patient was treated by splenorrhaphy 7 days after admission. Bleeding complications occurred in one patient after splenorrhaphy (bleeding from the pancreatic tail) and the bleeding vessel could be transfixed during the same anaesthetic. Four patients required reexploration after splenectomy for hemorrhage (2) and evacuation of infected haematomas. The Injury Severity Score (ISS) of the splenectomy and splenic preservation group was determined. Splenectomised patients showed in the postoperative follow-up a significantly increased infection rate (40%, p less than 0.02) when compared to patients with splenic preservation (10%) or nonoperative treatment (11%), even when they were matched in respect of multiple trauma using the Injury Severity Score (ISS).

Adolescent↗
PubMed1992

[Dose standardized management of patients with occlusive jaundice reduce morbidity and mortality?].

Patients with obstructive jaundice have a high incidence of complications. Invasive techniques required for definitive diagnosis and treatment compound the situation. In a prospective randomised trial we studied 54 patients over a 12-month period. All had obstructive jaundice (bilirubin greater than 100 mg/%). Prior to treatment, the trial protocol required correction of fluid balance (CVP), administration of albumin and vitamin K and an adequate urine output. Antibiotics were administered in accordance with a strict regime. The overall mortality was 7.5%, in elective cases with a mortality of 4%, in emergency cases with a mortality of 100%. The surgical treated patients had a higher incidence of complications than patients with interventional procedure, but not a higher mortality. Patients with obstructive jaundice will benefit from an adequate pre-treatment resuscitation and a standardised treatment policy after elimination of the obstruction.

Adult↗
PubMed1992

[Is surgical bile duct revision in choledocholithiasis still indicated?].

Endoscopic papillotomy with stone extraction is increasingly performed for the management of common bile duct stones either before cholecystectomy or as a sole procedure leaving the gallbladder in situ. We have therefore evaluated the method of operative common duct exploration. 94 cases with bile duct stones treated by cholecystectomy and common bile duct exploration were reviewed. The 30-day mortality was 2.1% with an overall morbidity of 19%. A retained stone was found on postoperative T-tube cholangiography in 6 patients and in all cases was removed percutaneously via the T-tube track. Patients were divided into three age groups (less than or equal to 60, 61-75, greater than 75 years). In each patient various risk factors were recorded. Correlation was made between age, risk factors and patient's morbidity. No correlation was found between age and morbidity. Patients with up to two risk factors had a morbidity of 10%. With three to four risk factors the morbidity increased to 19%, reaching 47% in patients with five and more risk factors. Cholecystectomy with common bile duct exploration is a safe procedure even in the elderly patient. Careful evaluation of risk factors is necessary. Endoscopic papillotomy with or without cholecystectomy should be considered in high risk patients.

Adult↗
PubMed1991

Adult polycystic disease of the liver.

Adult polycystic liver disease (APLD) is a rare disorder of liver parenchyma occasionally requiring surgical treatment. Its association with adult polycystic kidney disease has meant that as renal dialysis has become widely available there is an increased number of patients surviving with cystic liver changes. Although usually asymptomatic, patients with APLD may present with abdominal pain or swelling. Liver function is not usually compromised and computed tomography or abdominal ultrasonography are the most useful investigations. The complications of cyst rupture, infection, cholangiocarcinoma and compression of surrounding structures are discussed. Surgical treatment remains controversial, and the options of cyst puncture, fenestration with or without hepatic resection, and liver transplantation are reviewed.

Adult↗
PubMed1991

Combined surgical and interventional radiological approach for complex benign biliary tract obstruction.

In patients with complicated high benign biliary strictures surgical technique alone cannot exclude the possibility of recurrent problems, and hepatic atrophy/hypertrophy, portal hypertension and intrahepatic stones may all complicate surgical management. A multidisciplinary approach to these complex cases, which minimizes the need for repeated surgical interventions, has been pursued. Roux-en-Y hepaticojejunostomy was performed and an extended limb of the jejunum brought to the abdominal wall to allow access for later radiological intervention. Over a 30-month period 58 biliary-enteric anastomoses for benign disease were performed. Seventeen of these 58 patients were managed using the combined approach. Ten of these 17 patients had complex postcholecystectomy strictures and seven had strictures resulting from inflammatory disease, hepatic resection or congenital problems. A new classification of results of management of bile duct strictures is proposed. Seven patients were classified as 'excellent', six 'good', two 'fair' and two 'poor'. Results were obtained at a mean follow-up of 16 months and it seems likely that in some patients major surgical reinterventions were avoided.

Adult↗