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Biomedical subjects

L W Way

Publications and source records attributed to L W Way.

At least 91 records · Page 5Linked to original sources
PubMed1983

Diagnosis and treatment of gastric emptying disorders. Clinical usefulness of radionuclide measurements of gastric emptying.

We studied 53 patients with severe gastrointestinal symptoms thought to be due to a gastric motility disorder. Sixty-six percent had had a previous operation on the stomach, and 21 percent had insulin-dependent diabetes mellitus. Based on clinical, radiographic, and endoscopic findings, 48 patients were thought to have gastroparesis, 3 were thought to have dumping, and 2 had no diagnosis. Measurement of gastric emptying of solids showed that gastric emptying was normal in 12 patients, rapid in 15 patients, and slow in 26 patients. Further evaluation showed that half of the patients with normal gastric emptying, and one third of those with rapid gastric emptying had other diseases of the gastrointestinal tract that responded well to surgery. Of those patients with dumping, diet modification was effective in 40 percent, and half of those who did not respond to dietary manipulations did well after reoperation. Nineteen patients with delayed gastric emptying were treated with metoclopramide. Sixty percent of those without previous gastric surgery responded, whereas only 25 percent of those with previous gastric surgery had good results. The rate of gastric emptying improved following reoperation in 9 (90 percent) of 10 patients with delayed gastric emptying (4 who had not responded to metoclopramide). Gastric emptying was measured again in 15 patients after treatment. The changes after treatment paralleled the clinical response. These studies indicate that gastroparesis cannot be reliably diagnosed on the basis of clinical findings and standard tests. Gastric emptying studies are essential to diagnose and treat patients thought to have gastric motility disorders, and to evaluate the results of therapy.

Adult↗
PubMed1983

Cimetidine in the treatment of Zollinger-Ellison syndrome.

From 1977 to 1983 we used cimetidine as primary therapy for 17 patients with the Zollinger-Ellison syndrome. All patients were treated with oral doses of cimetidine, 300 to 600 mg, four times a day, unless symptoms of hyperacidity developed or until evidence of a potentially resectable tumor became available, at which time they underwent definitive therapy. Eleven (65 percent) had no response to cimetidine therapy, 7 of whom had symptomatic recurrent ulcers, 3 of whom had esophagitis, and 2 of whom had severe diarrhea. Eight of these patients were treated with total gastrectomy, two with successful tumor resection, and one with parietal cell vagotomy (which facilitated the control of hyperacidity with cimetidine). All operations except one were performed electively and there was no operative mortality.

Adolescent↗
PubMed1983

Resection of gastrinomas.

Exploratory laparotomy and a search for gastrinomas was performed in 52 patients with the Zollinger-Ellison syndrome (ZES). Gastrinoma tissue was resected in 11 patients (21%), 6 (12%) of whom appear to have been cured. After surgery, serum gastrin levels in these six patients have remained normal from 10 months to 10 years. In the 46 other patients, tumor was unresectable because of metastases or multiple primary tumors (21 patients; 40%) or inability to find the tumor at laparotomy (21 patients; 40%). Multiple pancreatic islet cell adenomata were found in six of seven patients with multiple endocrine neoplasia (MEN), indicating that patients with this condition usually have diffuse involvement of the pancreas. The results of CT scans correlated with findings at laparotomy in 13 of 16 patients. The smallest tumor detected by CT scans was 1 cm in diameter. CT technology is more accurate in finding gastrinomas now than in the past and has a useful role in preoperative evaluation. The possibility of resection should be seriously considered in every patient with Zollinger-Ellison syndrome. Abdominal CT scans, transhepatic portal venous sampling, and laparotomy should be used to find the tumor and to determine whether it is resectable. Using presently available methods, it should be possible to cure about 25% of patients with gastrinomas who do not have MEN and over 70% of those without MEN who appear to have a solitary tumor. Total pancreatectomy may be necessary to cure some patients with MEN, but that operation is rarely justified. The morbidity and mortality of surgical attempts at curing this disease have become minimal; we have had no deaths or serious complications following such operations in over 10 yrs. Total gastrectomy and indefinite use of H2-receptor blocking agents are the therapeutic options for patients with unresectable gastrinomas. Because H2-receptor blocking agents fail to control acid secretion in many patients after several yrs of therapy, total gastrectomy is indicated in a large proportion of patients whose tumors cannot be resected. Total gastrectomy in patients with ZES is also safe using current techniques; our last death following this operation for ZES occurred 15 yrs ago.

Adenoma, Islet Cell↗
PubMed1983

Nuclear magnetic resonance imaging characteristics of gallstones in vitro.

The nuclear magnetic resonance (NMR) imaging characteristics of gallstones of various composition from 36 patients were studied in vitro using a spin-echo imaging technique. The majority of gallstones (83%) produced no measurable NMR signal despite having a mean water content of 12% and a mean cholesterol content of 61%. Six (17%) of the stones had a weak but measurable signal in the center of the stone, which was thought to represent signal from water in clefts or pores within the stones. The mean water and cholesterol content of the stones with measurable signal did not differ significantly from that of stones with no signal. A possible explanation for these findings, based on the known NMR characteristics of solid materials, is offered.

Bilirubin↗
PubMed1983

Pigment sludge and stone formation in the acutely ligated dog gallbladder.

We studied the effects of stasis of gallbladder bile in a dog model. Three days after cystic duct ligation, all gallbladders contained sludge, and the mucosa was covered by densely adherent mucus with solid particles 1-4 mm in diameter (gravel). Thirty percent of the animals developed stones (greater than 4 mm), which appeared grossly like human pigment stones and microscopically like condensed biliary sludge. Centrifugation of bile yielded colorless pellets (3.8 +/- 3.2 mg/ml) at day 0 and pigmented pellets (33.1 +/- 11.0 mg/ml) at day 3 (p less than 0.05). Pellets contained 73 +/- 8% mucin by weight. Dissolved mucin in supernatant bile increased from 7.46 +/- 1.19 mg/ml (day 0) to 27.36 +/- 3.05 mg/ml (day 3) (p less than 0.001), while bilirubin concentration decreased from 127 +/- 12 mg/dl (day 0) to 71 +/- 16 mg/dl (day 3) (p less than 0.001). Cholesterol concentration increased but did not reach saturation, while the concentration of bile salt and phospholipid did not change. Mucin-bilirubin complexes formed and remained suspended as sludge initially. As bile mucin content increased, sludge particles coalesced, precipitated, and eventually formed gravel and stones. We suspect that stone formation in this setting occurs because of sequestration of biliary lipids by mucin.

Animals↗
PubMed1982

Peritoneovenous shunt for refractory ascites: operative complications and long-term results.

We studied the clinical course of 35 patients with refractory ascites who underwent 51 peritoneovenous shunts. Nine of them had hepatorenal syndrome (HRS). Operative complications included shunt malfunction, shunt infection, ascitic leak, fluid overload, and disseminated intravascular coagulation. Two of the patients without HRS died postoperatively. The survival rate in this group was 67% at one year and 43% at two years. Ascites was completely controlled in 83% of the survivors at two months and 50% at two years. Neither survival nor shunt patency were predictable. The shunt reversed HRS in three patients, but failed to do so in the other six. Late complications included shunt malfunction and infection. During the first two years of follow-up, five patients bled from esophageal varices. Liver failure was the sole cause of late death. Peritoneovenous shunt should be reserved for patients with truly refractory ascites, for whom it provides excellent palliation.

Adolescent↗
PubMed1982

Bilirubin and alkaline phosphatase values before and after surgery for biliary obstruction.

From a study of 178 patients who underwent operation for biliary obstruction, we found that preoperative bilirubin values above 14 mg/dl and alkaline phosphatase values over 5 times normal meant that common duct stones were an unlikely cause of the obstruction. Jaundice for more than 4 weeks before operation, bilirubin values greater than 10 mg/dl and the presence of significant fibrosis in the portal spaces indicated a lower than average chance of postoperative resolution of jaundice. After successful biliary surgery, the rate of decrease in serum alkaline phosphatase was haphazard and of little diagnostic value. The postoperative rate of decrease in the bilirubin values followed first-order kinetics and averaged 8 percent/day. This rate was not significantly influenced by the disease process, the length of preoperative clinical jaundice or the absolute height of the preoperative serum bilirubin level.

Alkaline Phosphatase↗
PubMed1982

Usefulness of diagnostic tests for biliary obstruction.

We studied the value of tests commonly used in diagnosing obstructive jaundice in 188 patients operated on for biliary obstruction. Ultrasonography had a diagnostic accuracy of 87 percent for gallbladder stones, 82 percent for dilated ducts, and 80 percent for pancreatic masses. Computed tomography was 93 percent accurate in diagnosing dilated ducts, and 93 percent accurate in diagnosing a pancreatic mass. Intravenous cholangiography gave useful information in only 4 of 21 patients. Among 45 patients, endoscopic retrograde cholangiopancreatography was technically successful in 91 percent and gave accurate diagnostic information in 86 percent and partially diagnostic information in 7 percent; it detected all cases of common duct stones and had a 91 percent sensitivity for detecting pancreatic cancer. Among 75 patients, transhepatic cholangiography was technically successful in 95 percent and provided accurate diagnostic information in 90 percent and partially diagnostic information in 3 percent; it detected all cases of common duct stones and 95 percent of cases of benign strictures. With persistent jaundice, ultrasonography should be the first test because it is less costly than computed tomography and provides similar information. If more information is needed, transhepatic cholangiography and endoscopic retrograde cholangiopancreatography are equally accurate; transhepatic cholangiography more often opacifies the proximal biliary tree and endoscopic retrograde cholangiopancreatography provides direct access to the ampulla of Vater and the pancreatic duct.

Bile Duct Diseases↗
PubMed1982

Sudden reversal of renal failure after take-down of a jejunoileal bypass. Report of a case involving hemorrhagic proctocolitis, and renal and hepatic failure late after jejunoileal bypass for obesity.

Hepatic and renal failure developed in association with severe enteritis and hemorrhagic proctocolitis in a patient who had had a jejunoileal bypass 8 yr previously for morbid obesity. Parenteral antibiotic treatment abolished the systemic manifestations of the enteritis, but did not change the course of the hepatic and renal failure, and prolonged hemodialysis was necessary. Liver function improved in response to hyperalimentation. Take-down of the jejunoileal bypass resulted in immediate improvement of renal function, and hemodialysis could be discontinued. Although there is no direct evidence supporting this theory, the course of this patient suggested that the renal failure was functional in origin, and was caused by a toxin generated as a result of the intestinal bypass. We suspect that the toxin originated from bacteria within the blind bowel loop. Its delivery to the renal circulation was probably facilitated by increased absorption from the ulcerated large intestine and by impaired clearance by the diseased liver. When the bacterial flora were returned toward normal by take-down of the bypassed intestine, the quantity of circulating toxins probably decreased, which allowed renal function to improve.

Acute Kidney Injury↗
PubMed1981

Factors influencing survival after therapeutic shunts. Results of a discriminant function and linear logistic regressions analysis.

Data on 100 consecutive patients undergoing portasystemic shunt at three hospitals of the University of California, San Francisco, were analyzed retrospectively to look for variables portending poor immediate and long-term outcome. As a determinant of early mortality after portacaval shunt, the Child's classification of the patient remains the single most important factor. If the patient is in Child's class C and has a hematocrit of less than 32 percent, he is even less likely to survive 30 days. The malnourished male patient who resumes drinking postoperatively is least likely to survive 1 year. Though short- and long-term mortality did not correlate with type of shunt, the prosthetic interposition mesocaval shunt was associated with an unacceptably high thrombosis rate of 20 percent in our institutions, and represented a technical failure to achieve the goal of preventing further variceal bleeding. No matter what type of shunt was performed, however, the 30 day mortality of Child's class C patients exceeded 50 percent. In the latter patients methods of treatment other than portasystemic shunts should be evaluated.

Adolescent↗
PubMed1981

Acute and chronic pancreatic pseudocysts are different.

Our experience supports the concept that acute and chronic pancreatic pseudocysts differ and require different plans of management. Patients who present with a chronic pseudocyst should be scheduled for operation promptly; internal drainage is almost always possible, spontaneous resolution is extremely rare, and delay only runs the risk of complications. Patients who are found to have an acute pseudocyst that develops during an attack of acute pancreatitis should be managed expectantly for 4 to 6 weeks; in them, spontaneous resolution may occur and surgical therapy is more satisfactory if the pseudocyst wall is allowed to mature enough that internal drainage is possible.

Acute Disease↗
PubMed1981

Management of recurrent and residual common duct stones.

When operating on patients with postcholecystectomy choledocholithiasis, a drainage procedure should be performed for the following indications: (1) multiple stones in the duct, (2) history of choledocholithotomy, (3) marked dilatation of the duct, (4) inability to remove all stones, and (5) presence of a ductal stricture. Patients with none of these are adequately treated by choledocholithotomy alone. Because endoscopic sphincterotomy has been shown to be safe and effective, however, it is currently our preferred method of treatment for the average patient with this condition.

Adult↗
PubMed1981

Biliary stricture.

Comparison of our results for the past 14 years with those from the period 1940 through 1968 shows that surgical therapy in the repair of biliary stricture has plateaued at a consistent level of more than 90 per cent success. The selection of an operative procedure and its conduct have become standardized based on the principles discussed earlier. The patients that have an unsatisfactory outcome are for the most part predictable. They are mainly those with biliary cirrhosis and its complications, ineradicable intrahepatic stone formation, or rare injuries that are technically incorrectable. Current experience reinforces our previous observation that a history of one or more previous unsuccessful repairs does not preclude success after another attempt. More than 80 per cent of such patients have been rendered symptom-free by stricture repair (Table 3). Since surgical therapy eliminates the need for external tubes and the perpetual morbidity of other forms of palliative therapy, it remains the mainstay of treatment for all but a handful of patients.

Adult↗
PubMed1981

Effect of chronic changes in rate of enterohepatic cycling on bile acid kinetics and biliary lipid composition in the rhesus monkey.

Although several studies have demonstrated an inverse relationship between size of the bile salt pool and frequency of enterohepatic cycling, most such data have been obtained in conditions where control of cycling frequency was not possible. In this study, we diverted bile from the bile duct of Rhesus monkeys into a reservoir and returned it to the duodenum at varying rates, a model that mimicked differences in frequency of gallbladder emptying. As cycling frequency increased from 1 to 8 cycles/day, size of the bile salt pool decreased from 1756 microM to 369 microM. Changes in fractional turnover rate parallelled changes in cycling frequency. The relative composition of the biliary lipids remained the same throughout the range of cycling frequencies. These data show that direct manipulation of cycling frequency had the predicted effects on other parameters of the enterohepatic circulation but did not give rise to lithogenic bile.

Animals↗
PubMed1980

In vitro investigation of the origin of echoes with biliary sludge.

To investigate the origin of echoes from "biliary sludge," concentrated bile and bile from 5 patients with ultrasound findings of biliary sludge were examined in a tissue-equivalent phantom before and after filtration through progressively smaller pore sizes. Filtration converted echogenic bile to echo-free bile. Examination of the filtration residue by light microscopy established that the source of echoes in biliary sludge was particles, predominantly pigment granules, with lesser amounts of cholesterol crystals. Partial chemical characterization by determination of vulnerability to different solvents verified that the sludge was mainly calcium bilirubinate.

Bile↗