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Biomedical subjects

M J Wexler

Publications and source records attributed to M J Wexler.

At least 37 records · Page 2Linked to original sources
PubMed1986

Hepatic resection for metastatic disease.

Hepatic resection for metastatic disease is reviewed in 30 patients (mean age 58.9 years). The primary site was the colorectum in 25; the other primary tumours were leiomyosarcoma, plasmacytoma, and adenocarcinoma (all of gastric origin), ocular melanoma and an unknown primary. Operative procedures included 7 wedge resections, 5 segmentectomies and 21 lobectomies (11 right, 4 extended right and 6 left). Major complications in seven patients included intraoperative hemorrhage in three, two of whom died, bile-duct injury in two, small-bowel infarction in one and cerebrovascular accident in one. Operative death rate was 6.7% (2 of 30). Thirteen patients were alive and free of disease a mean of 24 months after hepatic resection while 5 more were alive with disease at a mean of 36.9 months. Life-table analysis projected a 5-year survival of 50.3% for those with colorectal primaries, with no apparent difference in survival between patients with single (55.0%) and multiple (54.0%) metastases. Improved survival was projected for patients with metachronous (66.6%) versus synchronous (45.0%) tumours, primary Dukes' class A or B (66.1%) versus Dukes' class C (46.0%) tumours and those having wedge resection or segmentectomy (66.6%) versus lobectomy or extended lobectomy (48.0%). Hepatic resection for metastatic disease can be done with acceptable morbidity and mortality and the expectation of substantially prolonged survival particularly in patients with metachronous lesions or Dukes's A or B colorectal primary lesions.

Actuarial Analysis↗
PubMed1986

The septic abdomen: open management with Marlex mesh with a zipper.

The "open" abdomen has gained popularity in the management of severe intraabdominal sepsis. Drawbacks include evisceration, need for ventilator support, and recurrent abdominal sepsis. We have applied a more aggressive and effective technique consisting of abdominal "closure" with a Marlex mesh sheet containing a zipper. Manual exploration and lavage is performed daily through the zipper in the surgical intensive care unit. Ten patients with severe abdominal sepsis were treated for the following: fecal peritonitis (three patients), radiation enteritis with fistula (one patient), diverticular abscess and dehiscence (one patient), diffuse postoperative abdominal sepsis (two patients), and necrotizing pancreatitis (three patients). Thirteen meshes were inserted, four at first operation and nine at the second to sixth operations. Eight patients survived (80%). Only three patients required respirators; two died. Two patients underwent drainage of three defined abscesses in the surgical intensive care unit. Three patients underwent five major operations through the zipper. Intestinal stomas were present adjacent to the mesh in six patients and were not a management problem. No fistulas resulted from this technique. The Marlex/zipper was removed when all septic signs abated and adhesions were allowed to form (average of 10 to 12 days). Daily aggressive manual lavage of the abdomen through a Marlex mesh/zipper is rapid, simple, and well tolerated. It has permitted effective management of severe septic peritonitis and easier wound care. This technique merits further controlled trials to ascertain its ultimate benefit in survival.

Abscess↗
PubMed1984

Subacute endotoxemia in dogs with experimental cirrhosis and ascites: effects on kidney function.

To study the effect of low-grade continuous endotoxemia in normal and cirrhotic dogs, osmotic minipumps were filled with Escherichia coli endotoxin, implanted subcutaneously and arranged so that the endotoxin could be infused intravenously over a 7-day period in doses ranging from 2.5 to 100 micrograms/h. Observations were made at 3 and 7 days postinfusion. In normal dogs (N = 9), there was no effect on cardiac output or arterial pressure when doses as high as 50 micrograms/h were delivered into the circulation. Neither was there an effect on inulin or p-aminohippurate (PAH) clearances. At doses of 100 micrograms/h, dogs suffered a marked decrement in cardiac output, blood pressure, and renal perfusion and became lethargic at 3-7 days. In cirrhotic dogs, doses of 25 micrograms/h which had no effect in the control dogs, caused a significant decline in the glomerular filtration rate (59-21.5 mL/min) and CPAH (147-66 mL/min) at a time when cardiac output and blood pressure remained normal. At doses of 50 micrograms/h, cardiac output and blood pressure declined markedly and the dogs deteriorated quickly following 3-5 days of endotoxin. When endotoxin (25 micrograms/h) was given to dogs with acute biliary obstruction (serum bilirubin = 9.8 +/- 0.1 mg/dL) or to dogs with chronic thoracic caval constriction (which produced portal hypertension and ascites), no effect was observed on either central hemodynamics or renal perfusion. The selective renal vasoconstrictor effect observed in cirrhotic dogs could not be abolished by intravenous phentolamine or propranolol, inhibitors of alpha- and beta-adrenergic activity, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1984

Value of high-resolution computerized tomography in localizing diseased parathyroid glands.

Eighteen patients with hyperparathyroidism underwent high-resolution computerized tomography of the neck and superior mediastinum to assess the accuracy of the method in localizing diseased parathyroid glands preoperatively. The tomograms were correlated with surgical and pathological findings. Four scans were technically unsatisfactory. Of the remaining 14 scans, 8 showed an enlarged parathyroid gland; in 7 cases, the scan correctly identified the location of the diseased gland while in 1 case, the side of the lesion was incorrect. The other six scans did not show an abnormal parathyroid. These glands varied in size from 0.05 to 5.0 cm3 at the time of pathological examination. Three patients were undergoing re-exploration for persistent disease; technically acceptable scans were obtained in two and, in both, the location of the adenoma was correctly identified. Excluding patients with technically unsatisfactory scans, this technique has a sensitivity of 50% (7/14) and a false-negative rate of 43% (6/14) independent of gland size. However, in the eight scans interpreted as positive, the correct side of the lesion was localized in 7 (88%). This technique is not recommended for routine preoperative localization but may be of value in re-exploration for persistent disease.

Adenoma↗
PubMed1983

Esophageal procedures to control bleeding from varices.

Portal-systemic shunting of all types has failed to improve long-term survival in patients with bleeding esophageal varices and carries a high morbidity and prohibitive mortality in the emergency setting. Direct esophageal approaches are receiving renewed attention. Sclerotherapy promises to be the simplest, safest, and most effective treatment for acute bleeding. Rebleeding is frequent with this technique unless all the varices are subsequently obliterated. Even then, rebleeding may be a recurring hazard, albeit with reduced frequency and increasing interval. For the nonalcoholic patient with a significant life expectancy or in the young patient with cirrhosis, this can be a significant factor. Simple esophageal resection-transection using stapling devices is a rapidly accomplished, simple, and effective operative approach if combined with coronary vein ligation. This procedure deserves a trial earlier in such patients and in those who are failures of repeated sclerotherapy. Extensive esophagogastric devascularization preserving the paraesophageal veins--the Sugiura procedure--is a more extensive undertaking that is probably unnecessary for most and too dangerous for some. At present, it should be reserved for failures of other techniques. It shows promise of long-term effectiveness if performed safely on only certain patients.

Esophageal and Gastric Varices↗
PubMed1983

Renal blood flow in normal dogs and in dogs with experimental liver cirrhosis following the acute continuous infusion of endotoxin.

The purpose of this study was to determine if the renal circulation of normal and cirrhotic dogs behave similarly in response to an acute endotoxin infusion. Endotoxin was administered as a slow continuous infusion (13-26 micrograms/min) to a total of 20 normal dogs through the femoral vein, portal vein, or into the left renal artery. In each case, there was an initial increment in renal blood flow, of the order of 46%, while arterial blood pressure was actually declining. After 8-20 min, blood flow fell as perfusion pressure declined further. The initial increment in renal perfusion was not due to a hyperthermic response following the endotoxin. When similar doses were given to five dogs with chronic biliary cirrhosis and ascites, the biphasic response in renal perfusion was not observed, rather blood flow declined as perfusion pressure declined. When normal dogs were infused with bilirubin, bile salts, noradrenaline, and angiotensin in pressor doses, the subsequent infusion of endotoxin still produced the usual biphasic response in renal perfusion. Chronic elevation of portal pressure (but not acute elevation), volume contraction by diuresis or hemorrhage, and the infusion of bile intravenously, all abolished the biphasic response in renal perfusion and reproduced in normal dogs the response to endotoxin observed in cirrhotic dogs. Investigation of the factors causing the initial decrease in intrarenal vascular resistance in normal dogs following the endotoxin infusion implicated a role for histamine, kinins, and prostaglandins. We conclude there is a fundamental difference in the response of the renal circulation of normal and cirrhotic dogs to an endotoxin infusion, which may depend on failure of this latter group to release one or more humoral agents. This difference may be due to elevated portal pressure, a decreased effective arterial blood volume, or the products of bile having access to the circulation in cirrhotic dogs.

Animals↗
PubMed1983

Renal perfusion in dogs with experimental hepatic cirrhosis: role of prostaglandins.

Increased renal production of prostaglandins are thought to be important for the maintenance of kidney blood flow in advanced cirrhosis. In alert, unanesthetized dogs with chronic cirrhosis and ascites, produced by bile duct ligation, we measured inulin and p-aminohippurate (PAH) clearance before and after the intravenous administration of 2 mg/kg indomethacin, an inhibitor of prostaglandin production. Inulin and PAH clearance declined by 42 and 43%, respectively. This decline in renal perfusion was not associated with changes in blood pressure or cardiac output. If portal hypertension was prevented by creating an end-side portacaval anastomosis at the time of bile duct ligation, indomethacin was without effect on renal perfusion whether or not the dog had ascites. If ascites was completely mobilized in cirrhotic dogs with portal venous hypertension with the aid of a LeVeen valve, indomethacin depressed inulin and PAH clearance as usual during the steady-state period once all ascites had been removed. An attempt was made to determine some of the factors mediating the apparent increase in renal prostaglandin synthesis by administering various pharmacological antagonists. The inhibition of angiotensin effect with saralasin and the inhibition of kallikrein with aprotinin prevented the usual indomethacin effect. It is concluded that portal hypertension, but not a "sick liver per se, in cirrhosis activates the renin-angiotensin system to both produce renal vasoconstriction and stimulate prostaglandin synthesis, thereby normalizing renal perfusion. Renal kallikrein also appears to play a role, probably by augmenting renin release.

Animals↗
PubMed1983

Dogs with experimental cirrhosis of the liver but without intrahepatic hypertension do not retain sodium or form ascites.

Dogs with portal cirrhosis but without portal hypertension (end-to-side portacaval anastomosis) retain sodium and expand plasma volume before ascites formation. In our study, dogs were subjected to bile duct ligation and simultaneous side-to-side portacaval anastomosis (PCA) in order to create a canine model of hepatic cirrhosis without intrahepatic or portal hypertension. The effect of normalizing intrahepatic pressures in the face of venous outflow block on sodium handling was studied. 13 dogs survived the surgical procedures and were followed. Two dogs developed sodium retention and ascites at 5-6 wk (livers were cirrhotic) when the PCA spontaneously closed. 11 dogs were free of sodium retention and ascites for as long as 12 wks after surgery, while ingesting 35 meq/d of sodium. In this group glomerular filtration rate remained normal throughout the period of observation and there was no expansion of plasma volume. Nine of these dogs were then fed 85 meq/d of sodium; eight remained in sodium balance and one retained sodium and went on to develop ascites. When 10-15 mg i.m. of desoxycorticosterone acetate (DOCA) was given daily, five dogs developed sodium retention and ascites, while four escaped from DOCA. Dogs who developed ascites had either a partially occluded PCA (4/5) or a patent PCA, but with a significant portacaval pressure gradient of 9.5 cm H2O (1/5). In all four dogs who escaped from DOCA, the PCA was widely patent and the mean pressure gradient was only 1.6 cm H2O. Both groups were equally cirrhotic, as judged by histological and biochemical parameters. We conclude that normalizing intrahepatic pressure by providing an outflow tract for the cirrhotic liver will abolish that component of early renal tubular sodium retention not due to portal venous hypertension or ascites sequestration.

Animals↗
PubMed1983

An aggressive, nonshunting approach for control of bleeding esophageal varices.

Morbidity and mortality from variceal hemorrhage can be significantly reduced. A well-defined treatment protocol which obviates delay, procrastination and excessive blood loss is essential. Early aggressive endoscopic sclerotherapy is extremely safe and effective in controlling the acute hemorrhagic event. However, technical details remain to be standardized; rebleeding can be significant and sclerosing until roentgenologic obliteration is essential. Stapled esophageal transection and coronary vein ligation are a reasonable and effective surgical approach when necessary; however, the exact timing and place of this procedure in the therapeutic schema are not yet defined. It requires further phase one studies and not more randomized control trials! It can be difficult after recent sclerotherapy and would appear to require upper gastric devascularization or perhaps percutaneous embolization if gastric varices are venographically prominent. We have recently attempted to modify the procedure in such patients by stapling across the anterior and posterior gastric walls as an alternative or addition to complete esophageal transection. This is accomplished through a small gastrotomy adjacent to the gastroesophageal junction. Shunting procedures or more extensive surgical intervention does not appear necessary, desirable or warranted at this time; however, longer follow-up study is essential.

Aged↗
PubMed1980

Treatment of bleeding esophageal varices by transabdominal esophageal transection with the EEA stapling instrument.

Six cirrhotic patients underwent emergency esophageal transection utilizing the EEA Auto Suture stapling instrument for treatment of unrelenting variceal hemorrhage. All were grade C, and the combination of ascites, encephalopathy, and jaundice was present in four. All were critically ill with ancillary medical problems, including recent subtotal gastrectomy with sepsis and dehiscence, coexisting malignant biliary obstruction, and respiratory insufficiency. All were anergic to skin testing. Four died in the postoperative period, primarily of problems related to sepsis and ascites present before operation. Autopsy showed a well-healed anastomosis without stricture and complete interruption of the varices in all. No patient had recurrent bleeding. All received oral or tube feedings after operation. Two survive at 2 and 1.5 years with no recurrence of varices. This is a rapid, simple, and effective technique which can be done with minimal blood loss or training. There is no diversion of portal blood and minimal interruption of collateral circulation. Whereas the long-term benefits in terms of rebleeding are not yet known, results to date suggest a trial earlier and in better risk patients as a definitive treatment procedure.

Aged↗
PubMed1980

Misleading appearance of biliary dilatation.

Dilated biliary radicles demonstrated on 99mTc-dimethyl-acetanilide-imino-diacetic-acid (99mTc-IDA) imaging suggested biliary obstruction, and led to transhepatic cholangiography and endoscopic retrograde cholangiopancreatography. Both showed a biliary tree of normal diameter.

Adult↗