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Biomedical subjects

L W Way

Publications and source records attributed to L W Way.

At least 73 records · Page 4Linked to original sources
PubMed1987

Risk of biliary surgery in patients with hyperbilirubinemia.

Previous studies have suggested a direct relationship between the serum bilirubin level and the risk of operation. However, patients with high bilirubin levels are usually older and have associated conditions unrelated to jaundice that may contribute to the development of postoperative complications. We studied the courses of 98 consecutive patients who were admitted with biliary obstruction and a serum bilirubin level of 10 mg/dl or greater and underwent operation. Sixty-one had neoplastic obstructions, 26 had benign biliary strictures, 8 had choledocholithiasis, and 3 had other obstructive lesions. Comorbid factors were evaluated and assigned a score to reflect their severity. Neither age nor advanced local cancer was considered to be a comorbid factor. Biliary obstruction was treated by resection of the bile duct, the pancreas, or both in 28 patients, by bilioenteric bypass in 55 patients, and by other operations in 15 patients. Postoperatively, complications developed in 30 patients and 8 died. There was no correlation between the admission serum bilirubin level, hematocrit value, or serum albumin level and the development of complications or death. There was a strong correlation between the presence of severe associated disease and the risk of postoperative complications or death. Nineteen of 81 patients with a comorbid score below 4 had a complication compared with 11 of 17 patients with scores of 4 or higher (p less than 0.01). Two of the 81 patients with scores below 4 died compared with 6 of 17 patients with a score of 4 or higher. These findings show that postoperative deaths and serious complications in patients with severe jaundice are principally the result of uncontrolled associated disease and that jaundice per se does not contribute substantially to an undesirable outcome.

Aged↗
PubMed1987

Factors affecting the morbidity of elective liver resection.

To identify the determinants of morbidity and mortality after hepatic lobectomy, we studied 17 potential risk factors in 58 consecutive patients who had right hepatic lobectomy (39 patients), left hepatic lobectomy (10 patients), extended right hepatic lobectomy (6 patients), and left lateral segmentectomy (3 patients). The lesions were benign neoplasm (11 patients), primary malignancy (12 patients), metastatic neoplasm (28 patients), and inflammatory conditions, namely, stones, ductal strictures, and abscess (7 patients). Two patients died (3.8 percent), one from operative hemorrhage and the other from sepsis. Major complications occurred in 29 patients (50 percent). The presence of diabetes or pulmonary disease correlated with the development of complications. Infection occurred in four of five patients with diabetes. The incision was extended into the thorax in nine patients, all of whom had complications. The mean weight of the resected specimen did not differ between patients who underwent thoracotomy and those who did not, but the two largest specimens (over 2 kg) were removed without thoracotomy. Minor complications developed in two patients with benign tumors. Biliary fistulas developed in three of seven patients with inflammatory conditions. Infectious complications were decreased in the presence of adequate perioperative antibiotics and closed drainage of the subphrenic space. These data show that in fit patients, elective liver resection can be performed with a low morbidity and mortality; diabetes, pulmonary disease, and inflammatory lesions increase the risk of hepatic resections; adequate antibiotics and closed drainage decrease the risk of infection; and thoracotomy markedly increases the chance of complications. Finally, since elective resection can nearly always be performed without thoracotomy, it should be avoided in most patients.

Adult↗
PubMed1987

Pigment gallstones form as a composite of bacterial microcolonies and pigment solids.

Although previous studies have suggested that bacteria may contribute to pigment gallstone formation, the current experiments provide evidence that bacteria have a central role in this process. The studies included scanning electron microscopy (SEM) of gallstones, measurements of bacterial adherence to gallstones in vitro, and determination of glycocalyx elaboration by biliary bacteria. Gallstones from 85 patients were studied under SEM. Twenty-five (78%) of 32 pigment stones had evidence of bacterial microcolonies throughout the interior of the stones. Bacteria were absent from the interior of all 35 cholesterol stones studied. Composite stones (stones with separate pigment and cholesterol portions) showed evidence of bacteria within the pigment portions in 14 (78%) of 18 cases. Biliary bacteria adhered to the surface of pigment gallstones in vitro in 35 (90%) of 39 cases, compared with three (8%) of 39 cholesterol stones. Glycocalyx was elaborated by bacteria isolated from nine (82%) of 11 patients with either pigment or composite gallstones. One (33%) of three bacterial species from patients with cholesterol gallstone disease produced glycocalyx. These studies indicate that most pigment gallstones obtained from patients in Western cultures form as a composite of bacteria, bacterial glycocalyx, and pigment solids. Bacteria were found in the majority of black as well as brown pigment stones. These findings serve as the basis of a new theory of pigment stone formation in which bacteria and glycocalyx are postulated to be responsible for the precipitation and subsequent agglomeration of bilirubin pigment. These results also suggest that sepsis is more common in pigment gallstone disease because the stones can serve as a sanctuary for bacteria.

Adult↗
PubMed1986

Intestinal transit of food after total gastrectomy and Roux-Y esophagojejunostomy.

We examined small bowel transit of solid food in 10 patients 3 to 30 months after total gastrectomy and Roux-Y esophagojejunostomy and compared the transit pattern with that in five control subjects. All persons ate a test meal consisting of 213 g of beef stew mixed with 30 g of chicken liver which was labeled with 1 mCi of technetium 99m sulfur colloid, and they stood in front of a gamma scintillation camera and were studied for 6 to 10 hours. Solid food passed rapidly from the esophagus through the Roux-Y limb and became uniformly distributed throughout a long segment of the small intestine. Mouth-to-colon transit time was 223 +/- 18 minutes in the control subjects and 298 +/- 37 minutes in the patients with gastrectomy. Small bowel transit of the head of the meal was 187 +/- 19 minutes in the control subjects and 293 +/- 37 minutes in the patients (p less than 0.02). Transit time of the tail of the meal was 175 +/- 26 minutes in the control subjects and 396 +/- 28 minutes in the patients (p less than 0.001). After total gastrectomy and Roux-Y esophagojejunostomy, the proximal jejunum does not act as a reservoir; transit of food through the small intestine is slower than in control subjects, and because the proximal jejunum empties rapidly during eating, a meal of normal size can be consumed. These findings do not support the idea that an artificial gastric reservoir is important after total gastrectomy.

Adult↗
PubMed1986

Routine colonoscopy in the management of colorectal carcinoma.

A prospective study of the role of preoperative and routine follow-up colonoscopy in 75 patients with colon and rectal carcinoma disclosed that additional premalignant or malignant lesions were detected and successfully treated in 44 percent of patients. These included four synchronous and three metachronous carcinomas. Timely diagnosis and treatment of such tumors and secondary prevention of metachronous carcinomas by polypectomy is a major identifiable benefit of close follow-up examinations of these patients. No other test compares favorably with colonoscopy in this regard. These data support the conclusion that colonoscopy should be performed routinely preoperatively and every 6 to 12 months after colectomy for carcinoma.

Aged↗
PubMed1986

Gallbladder filling and emptying during cholesterol gallstone formation in the prairie dog. A cholescintigraphic study.

We studied gallbladder bile flow before, during, and after cholesterol gallstone formation in the prairie dog using infusion cholescintigraphy with 99mTc-diethyl iminodiacetic acid. In 18 fasting animals partitioning of bile between gallbladder and intestine was determined every 15 min for 140 min, and gallbladder response to cholecystokinin (5 U/kg X h) was calculated from the gallbladder ejection fraction. Ten prairie dogs were then placed on a 0.4% cholesterol diet and 8 on a regular diet, and the studies were repeated 1, 2, and 6 wk later. The proportion of hepatic bile that entered the gallbladder relative to the intestine varied from one 15-min period to the next, and averaged 28.2% +/- 5.1% at 140 min. Partial spontaneous gallbladder emptying (ejection fraction 11.5% +/- 5.6%) was intermittently observed. Neither the number nor the ejection fraction of spontaneous gallbladder contractions changed during gallstone formation. By contrast, the percent of gallbladder emptying in response to cholecystokinin decreased from 72.1% +/- 5% to 25.9% +/- 9.3% (p less than 0.025) in the first week and was 14.3% +/- 5.5% at 6 wk (p less than 0.01 from prediet values, not significant from first week). Gallbladder filling decreased from 28.2% +/- 5.1% to 6.7% +/- 3% (p less than 0.01), but this change was only observed after 6 wk, when gallstones had formed. This study shows that bile flow into the gallbladder during fasting is not constant; the gallbladder contracts intermittently; gallbladder emptying in response to exogenous cholecystokinin is altered very early during gallstone formation; and gallbladder filling remains unaffected until later stages, when gallstones have formed.

Animals↗
PubMed1986

Transport of fluid and biliary lipids in the canine gallbladder in experimental cholecystitis.

In acute cholecystitis the cystic duct is usually obstructed by a gallstone and the gallbladder is often tensely distended with clear fluid. Because these findings suggest that fluid absorption in the gallbladder may be reversed in cholecystitis, we examined the effect of inflammation on the gallbladder mucosal function in dogs. In 20 dogs cholecystitis was induced by ligating the cystic duct and allowing inflammation to develop from bile stasis and the presence of a chronic indwelling cannula in the gallbladder. Every morning an aliquot of normal hepatic bile was infused into the gallbladder through a cannula in the gallbladder fundus. After either 4 or 24 hr the gallbladder contents were aspirated, the volume was measured, and the concentrations of bile acids, cholesterol, phospholipids, and protein were determined. Changes in volume were checked using [14C]PEG as a nonabsorbable tracer. A net absorption of fluid, bile acids, cholesterol, and phospholipids occurred during the first 24 to 48 hr after ligation of the cystic duct. Thereafter, fluid, cholesterol, and protein were secreted into the lumen, but absorption of bile acids continued. The lithogenic index of bile placed in the inflamed gallbladder was always greater when the bile was removed 24 hr later. The rate of fluid secretion into the lumen of the inflamed gallbladder increased after a meal and decreased after indomethacin. These findings demonstrate that inflammation can stimulate the gallbladder mucosa to secrete fluid, a process that may be important in the pathophysiology of acute cholecystitis in man. Since inflammation also resulted in an increased cholesterol saturation of gallbladder bile, cholecystitis per se may contribute to the formation of cholesterol gallstones.

Animals↗
PubMed1985

Alkaline reflux gastritis and the effect of biliary diversion on gastric emptying of solid food.

We prospectively studied 15 consecutive patients treated for alkaline reflux gastritis to determine the gastric motility pattern associated with this disease and the effects of Roux-Y gastrojejunostomy on gastric emptying. Eleven patients had previous antrectomies (the Billroth I procedure in 4 and the Billroth II procedure in 7), and 4 had previous cholecystectomies. Gastric emptying was measured before and after Roux-Y reconstruction by computer analysis of data from a scintillation camera using technetium 99m tagged chicken liver mixed with beef stew. Gastric emptying was also measured in another 10 patients who had previous Roux-Y gastrojejunostomies and were thought from clinical findings to have gastroparesis. In the patients with alkaline gastritis, before surgery gastric emptying was normal in 25 percent, rapid in 45 percent, and delayed in 30 percent. After Roux-Y reconstruction, the rate of gastric emptying increased in 25 percent of patients, decreased in 45 percent, and did not change in 30 percent. Gastric bezoars developed in half of the patients whose gastric emptying decreased after surgery. There were no technical features of the operations nor mechanical abnormalities of the reconstructions that characterized the patients whose gastric emptying slowed postoperatively. Forty percent of the patients studied only after Roux-Y reconstruction had rapid gastric emptying, 30 percent had normal gastric emptying, and 30 percent had delayed gastric emptying. These data show that patients with alkaline reflux gastritis do not have a single pattern of gastric emptying, and Roux-Y reconstruction has no consistent effect on gastric emptying.

Adult↗
PubMed1985

Gallbladder filling and response to cholecystokinin are not affected by vagotomy.

We studied the effects of vagotomy on gallbladder (GB) motility in prairie dogs and humans with infusion cholescintigraphy. Twelve male prairie dogs were anesthetized and given an intravenous infusion of 120 microCi of diethyl-HIDA for 150 minutes. Images were acquired every 10 minutes. Then cholecystokinin (CCK)-8, 1.5 micrograms/kg, was given as a bolus, and images were acquired for another 30 minutes. We repeated the studies giving 300 micrograms/kg of atropine 20 minutes before administration of CCK-8. All animals underwent truncal vagotomy, and the studies were repeated 1 and 3 months later. The GB filled in a stepwise fashion; partitioning of bile varied from one 10-minute period to the next and averaged 20% +/- 2%/80% +/- 3% during the 150-minute period. Episodic partial GB emptying (ejection fraction 19% +/- 2%; intervals of 70 +/- 5 minutes) occurred during this phase. GB filling and partitioning of bile were unchanged after vagotomy. GB ejection fraction in response to CCK-8 was 69% +/- 6% in controls, 74% +/- 5% after atropine, 78% +/- 8% 4 weeks after vagotomy, and 66% +/- 6% 3 months after vagotomy. Sixteen human subjects were studied after parietal cell vagotomy (six patients) or truncal vagotomy and drainage (10 patients). GB filling average 2.5% +/- 2% per minute in patients who underwent truncal vagotomy and 3% +/- 1% per minute in patients who underwent parietal cell vagotomy. GB emptying in response to CCK-33 (0.02 U/kg/min) was 74% +/- 7% in patients who underwent truncal vagotomy and 82% +/- 4% in patients who underwent parietal cell vagotomy. Thus neither GB filling nor GB emptying in response to CCK was altered by cholinergic blockade or vagotomy.

Animals↗
PubMed1984

Recurrent biliary stricture. Patterns of recurrence and outcome of surgical therapy.

We analyzed the course of 50 consecutive patients with recurrent biliary stricture (at least one previous repair) to determine the pattern of recurrence and the outcome of additional treatment. The presenting manifestations included cholangitis in 40 percent of the patients, jaundice in 30 percent, and pain in 17 percent. Sixty-seven percent had become symptomatic within 2 years of their previous repair and 90 percent within 7 years. Ten (20 percent) patients were treated by end-to-end anastomosis of the bile duct, and 40 (80 percent) patients by bilioenteric anastomosis (hepaticojejunostomy in 32 patients and hepaticoduodenostomy in 8). Two patients (4 percent) died postoperatively. After repair of recurrent stricture, 38 (76 percent) patients had no further symptoms. In 11 (22 percent), another recurrence developed: 6 (55 percent) of the 11 did well after another operation and in 4 (36 percent), a third recurrence developed which was successfully treated by a fourth operation in 3 of the patients. Thus, two thirds of recurrent strictures were evident by 2 years and 90 percent by 7 years. The chance of another recurrence was about 25 percent after treatment of a first recurrence. There was no evidence that prolonged stenting contributed to a good result. Treatment of recurrent stricture should consist of anastomosis between the duct and the intestine, usually a hepaticojejunostomy.

Biliary Tract Diseases↗
PubMed1984

Composition and morphologic and clinical features of common duct stones.

No systematic study of the composition of common duct stones has been carried out to date. In this study, we assessed the chemical composition and morphologic characteristics of common duct stones from 115 patients, and compared them with gallbladder stones in 67 patients who had both. Visually and chemically, common duct stones could be divided into two groups: cholesterol stones and pigment stones. Cholesterol common duct stones contained 83 +/- 1 percent cholesterol, 2.3 +/- 0.4 percent bilirubin, and 5.5 +/- 1 percent insoluble pigment residue. Pigment common duct stones contained 7 +/- 1 percent cholesterol, 24 +/- 2 percent bilirubin, and 38 +/- 3 percent pigment residue. There were two subgroups of pigment stones: one with large amounts of bilirubin and one with large amounts of pigment residue. A high proportion (46 percent) of common duct stones were composed of pigment. Patients with pigment common duct stones were more likely to have cholangitis and pancreatitis than were patients with cholesterol stones. It was not possible to distinguish primary from secondary stones on morphologic grounds. In 65 of 67 patients (97 percent), gallbladder stones and common duct stones were of the same chemical type. Morphologically, cholesterol common duct stones were very similar (3.6+ on a scale of 0 to 4+) to their counterparts. Pigment common duct stones and gallbladder stones were less similar (2.4+). Chemically, cholesterol common duct stones were identical to their gallbladder counterparts. Pigment common duct stones regularly contained a greater fraction of bilirubin and less pigment residue than associated gallbladder stones (p less than 0.05). Earthy common duct stones were associated with earthy gallbladder stones, and were chemically indistinguishable from other pigment stones. These data suggest that all cholesterol common duct stones, and when the gallbladder is present, most pigment common duct stones, are secondary. The latter stones, however, probably grow after entering the duct, adding pigment with a high proportion of bilirubin relative to pigment residue.

Bile Pigments↗
PubMed1984

Follow-up of patients with colorectal cancer.

In our follow-up study of 65 patients after curative surgery for colorectal cancer, tests other than history and physical examination detected only two cases of potentially curable recurrent colorectal cancer. As a routine follow-up test, carcinoembryonic antigen determination is preferable to computerized tomographic scanning, since the sensitivity and specificity of carcinoembryonic antigen and computerized tomographic scanning were found to be equivalent and carcinoembryonic antigen is much less expensive. There was no benefit to the routine use of liver function tests or chest roentgenograms during follow-up. Since barium enema contributed little to what colonoscopy accomplished with greater comfort to the patient, barium enemas should be used only when colonoscopy is not totally successful in reaching the cecum. The most beneficial aspect of the follow-up of these patients is probably the elimination of future metachronous lesions by removal of small, benign polyps.

Adenocarcinoma↗
PubMed1984

Surgical treatment of chronic pancreatitis.

We studied the course of 100 consecutive patients who underwent surgery for pain or biliary obstruction from chronic pancreatitis or both between 1958 and 1982. Patients with pancreatic pseudocysts were excluded. Ten patients had pancreatic resection after previous pancreatic surgery had failed to control pain. Ten of 47 patients (21 percent) studied between 1972 and 1981 had bile duct entrapment from chronic pancreatitis and required biliary bypass operations. The results of longitudinal pancreaticojejunostomy were good in 67 percent of the patients, fair in 18 percent of the patients, and poor in 15 percent of the patients. The results of partial pancreatectomy were good in 60 percent of the patients (all with disease limited to the tail), fair in 20 percent of the patients, and poor in 20 percent of the patients. The results of subtotal pancreatectomy were good in 31 percent of the patients, fair in 37 percent of the patients, and poor in 32 percent of the patients. The results of pancreatic resection in patients with previous unsuccessful surgery for pain relief were good in only 10 percent of the patients. Biliary obstruction is present in many patients with chronic pancreatitis and must be treated surgically to prevent the development of biliary cirrhosis. Hemipancreatectomy is useful in patients with disease limited to the tail. The results of subtotal pancreatectomy are discouraging, especially in patients with a previous unsuccessful operation for pain. When the pancreatic duct is dilated, however, longitudinal pancreaticojejunostomy gives long-lasting relief of pain in most patients.

Adolescent↗
PubMed1984

Pleuropancreatic fistula: endoscopic retrograde cholangiopancreatography and computed tomography.

The complementary use of endoscopic retrograde cholangiopancreatography and computed tomography in the diagnosis and management of pleuropancreatic fistulas is described in relation to four cases in which computed tomography revealed the thoracic extension of a pancreatic fistula not demonstrable by endoscopic retrograde cholangiopancreatography, although the latter indicated an abnormal pancreatic duct. The complementary use of both techniques may be necessary to define the pathologic anatomy so that the appropriate therapy, particularly the surgical approach, can be decided.

Adult↗
PubMed1983

Abdominal abscess. A surgical strategy.

To reassess the role of laparotomy and extraserosal drainage in the treatment of patients with abdominal abscess, we analyzed the course of 79 patients who underwent 97 operations to treat 120 abdominal abscesses during a five-year period. In 66 clinical episodes the abscess was drained by the most direct approach. Sepsis resolved with a single operation In 80% of these patients, five patients (8%) required a second operation for drainage for an abscess, and eight patients (12%) died. In 31 clinical episodes, the abscess was drained by a laparotomy. Sepsis resolved with a single operation in 61% of these patients, seven patients (21%) had a second abscess, six patients (19%) required a second operation to drain a metachronous abscess, and six patients (19%) died. When the location or number of abscesses was diagnosed incorrectly, the success rate of therapy fell substantially. Since most abdominal abscesses can now be accurately diagnosed preoperatively, most abscesses should be drained by a direct approach. Exploratory laparotomy is indicated when preoperative localization is unsuccessful, when sepsis has not resolved after other methods of drainage, or when the patient has a concomitant abdominal condition that must be treated surgically.

Abdomen↗
PubMed1983

Effect of acid secretory capacity and chronic endogenous hypergastrinemia on pancreatic secretion and intestinal morphology in the rat.

To study the trophic effects of gastrin on the gastrointestinal tract, chronic endogenous hypergastrinemia was produced in rats by implantation of the gastric antrum into the colon. Rats were sham-operated (normal gastrin, normal acid) or were prepared with BII gastrojejunostomy and antral resection (low gastrin, low acid), or BII gastrojejunostomy and antral implantation into colon (high gastrin, acid present). To separate effects of hypergastrinemia from those of acid hypersecretion, two additional groups were prepared with total gastrectomy and either resection of the antrum (low gastrin, no acid) or antral implantation into colon (high gastrin, no acid). After 12 weeks, the pancreatic secretory response to secretin was measured. The animals were then sacrificed, and liver, pancreas, small intestine, and colon were weighed. In separate groups of animals villous height and width and crypt depth of small intestine and transverse colon were measured. Serum gastrin concentrations increased three- to fivefold in fasting and fed antral implant animals. Serum gastrin levels in the fed state were lower in antrectomy rats compared to controls but did not differ in the fasting rats. Pancreas and colon were heavier in all hypergastrinemic rats. Liver weights did not differ between hypergastrinemic animals and controls. Stimulated pancreatic bicarbonate secretion following secretin infusion was elevated only in hypergastrinemic, hyperacidic rats. Hypertrophy of the small bowel was seen in antral implant rats only when the gastric remnant was preserved (ie, when acid was present). Colonic mucosal thickness was increased in antral implant rats with or without gastrectomy. No significant increases in small-bowel villous height or crypt depth were found in antral implant rats. Thus, chronic endogenous hypergastrinemia caused pancreatic and colonic hypertrophy independent of acid secretion. In addition to hypergastrinemia, gastric hyperacidity was also needed for enlargement of small bowel or increase in secretin-stimulated pancreatic bicarbonate secretion.

Animals↗