Search PubMed⌕ Search

Biomedical subjects

M Larvin

Publications and source records attributed to M Larvin.

At least 37 records · Page 2Linked to original sources
PubMed2000

Laparoscopic treatment of Mirizzi syndrome.

Mirizzi syndrome is a rare disorder and remains a surgical challenge. It is generally considered as a contraindication to laparoscopic surgery. Three patients with Mirizzi type II syndrome and two patients with Mirizzi type I syndrome were treated laparoscopically. Partial cholecystectomy with fundus-first dissection of the gallbladder was performed, and closure of the fistula in type II syndrome was achieved over a T-tube. The common bile duct (CBD) was explored in one patient using a choledochoscope through the fistula. The procedure was completed laparoscopically in all five patients. The three patients with type II syndrome had residual CBD stones, which were associated with significant morbidity and mortality. Laparoscopic treatment of Mirizzi type I syndrome is technically feasible and safe. For Mirizzi type II syndrome, laparoscopic CBD exploration is demanding and experience, skill, and the full spectrum of modern technology are required.

Cholecystectomy, Laparoscopic↗
PubMed1999

Laparoscopic surgery combined with preservation of the spleen for distal pancreatic tumors.

BACKGROUND: Laparoscopic distal pancreatectomy combined with spleen salvage by preservation of the splenic vessels has been described in selected patients with islet cell tumors. METHODS: Laparoscopic resection of the left side of the pancreas with spleen preservation on the vasa brevia was attempted in six consecutive patients. RESULTS: Four distal pancreatectomies with spleen preservation were completed laparoscopically. There were two conversions to laparotomy. The median operating time was 300 min (range, 240-360). There was no mortality, but two patients developed a pancreatic fistula. The median postoperative hospital stay was 34.5 days (range, 5-60). All the patients remain well at a median follow-up of 30 months (range, 22-41). CONCLUSIONS: Minimally invasive surgery for distal pancreatic tumors is feasible and appropriate for most benign tumors. The spleen can be safely preserved laparoscopically on its blood supply from the short gastric vessels. The operative technique and especially the closure of the pancreatic stump need further study.

Adenocarcinoma↗
PubMed1999

Micropuncture laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy (LC) significantly reduces the discomfort and disability typically associated with open cholecystectomy, but there is still room for improvement. METHODS: In order to further reduce the trauma of access, we have introduced a technique of micropuncture laparoscopic cholecystectomy (MPLC) that utilizes three 3-mm cannulae in addition to the standard 10-mm cannula at the umbilicus. MPLC was performed in 25 patients (median age, 52 years; m/f, three of 22) with symptomatic cholelithiasis. RESULTS: The operation was completed in all patients. The median duration of surgery was 75 min (range, 45-180). Sixteen patients were discharged the same day and nine patients the next day. All the patients had an uncomplicated recovery. Only eight patients requested postoperative analgesia while in hospital. Micropuncture exploration of the bile duct was carried out in one patient. CONCLUSIONS: MPLC is a feasible and safe technique that appears to improve on the benefits of LC; it makes the operation even more feasible as a day-surgery procedure.

Ambulatory Surgical Procedures↗
PubMed1999

Randomized comparison between low-pressure laparoscopic cholecystectomy and gasless laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy using low-pressure pneumoperitoneum (8 mmHg) minimizes adverse hemodynamic effects, reduces postoperative pain, and accelerates recovery. Similar claims are made for gasless laparoscopy using abdominal wall lifting. The aim of this study was to compare gasless laparoscopic cholecystectomy to low-pressure cholecystectomy with respect to postoperative pain and recovery. METHODS: Thirty-six patients were randomized to low-pressure or gasless laparoscopic cholecystectomy using a subcutaneous lifting system (Laparotenser). RESULTS: The characteristics of the patients were similar in the two groups. The procedure was completed in all patients in the low-pressure group, but two patients in the gasless group were converted to pneumoperitoneum. There were no significant differences in postoperative pain and analgesic consumption, but patients in the gasless group developed shoulder pain more frequently (50% vs 11%, p < 0.05). Gasless operation took longer to perform (95 vs 72.5 min, p = 0.01). CONCLUSIONS: Gasless and low-pressure laparoscopic cholecystectomy were similar with respect to postoperative pain and recovery. The gasless technique provided inferior exposure and the operation took longer, but the technique may still have value in high-risk patients with cardiorespiratory disease.

Adult↗
PubMed1998

Laparoscopic cholecystectomy after pancreatic debridement.

BACKGROUND: Pancreatic debridement is a lifesaving operation in patients with severe acute pancreatitis and pancreatic or peripancreatic necrosis. Even in the presence of gallstones, cholecystectomy may be avoided during the procedure, but definitive treatment of the stones is needed at a later stage. METHODS: Five patients (median age 58 years) underwent laparoscopic cholecystectomy, at a median time interval of 15 months, after pancreatic debridement via a dome-shaped upper abdominal incision for severe acute pancreatitis. The use of alternative methods for primary access, additional cannulae to enable division of adhesions, the harmonic scalpel, and the fundus first technique made the laparoscopic approach possible and safe. RESULTS: The median operating time was 130 min. Four patients were discharged home the first or second postoperative day. One patient required a "mini-laparotomy" for drainage of a periumbilical hematoma and was discharged on the 13th day. CONCLUSIONS: Laparoscopic cholecystectomy can be considered an effective and safe approach for the treatment of gallstones in patients who have undergone pancreatic debridement.

Adult↗
PubMed1997

T2-weighted and dynamic enhanced MRI in acute pancreatitis: comparison with contrast enhanced CT.

The purpose of this study was to compare T2-weighted and dynamic contrast enhanced MRI with contrast enhanced CT in patients with severe acute pancreatitis. Thirty-two patients were examined using axial T2-weighted spin-echo imaging (TR 1801, TE 15/90) and a multi-slice rapid gradient-echo sequence (TR 135, TE 4, FA 80 degrees) (FLASH) in axial and coronal planes. Fifteen 5 mm axial slices at 10 mm intervals were acquired during a single breath-hold of 19 s before, and at 10 and 40 s after a bolus injection of Gd-DTPA. Additional FLASH images in the coronal plane were obtained 2 min after injection of contrast medium. MR was compared with contemporary enhanced CT by two blinded observers who scored pancreatic viability and the content of intra and extra-pancreatic fluid collections. The presence of gas, calcification and haemorrhage was noted. Abnormalities in adjacent organs, evidence of vascular occlusion and indicators of aetiology were also recorded. MR and CT were concordant in distinguishing viable pancreatic tissue from areas of necrosis. MR appeared to be more effective than CT in characterizing the content of fluid collections and in demonstrating gall stones, although CT remains superior in detecting flecks of gas and calcification. MR carries some advantages over CT and can be regarded as an alternative primary technique in patients with severe pancreatitis.

Acute Disease↗
PubMed1997

Assessment of severity and prognosis in acute pancreatitis.

Assessment of severity and prognosis in acute pancreatitis was originally driven by clinicians' needs for the prediction of outcome, together with the requirement of researchers for objective measurement of severity. Evaluation of the multitude of competing systems has been hindered by varying definitions of severity, incomplete reporting and a lack of comparative data. Although clinical assessment, Ranson and Glasgow scores remain predominant, the recent literature reflects how needs have changed, as a result of improved understanding of the biological events underlying attacks and technological advances. The Atlanta International Symposium should provide a suitable framework for progress.

Acute Disease↗
PubMed1996

Circulating mediators in acute pancreatitis as predictors of severity.

The case mortality for acute pancreatitis in the UK has remained largely unchanged, at just under 10% for the last 30 years. This is despite improvements in intensive therapy, radiology and surgical interventions. Acute pancreatitis also remains unpredictable. Organ system failure and pancreatic collections may develop either suddenly, or insidiously, and thus go undetected. Reducing mortality depends on better understanding of pathophysiology and more specific therapeutic approaches, but prognostic systems for the early identification of severe attacks may improve the success of current supportive therapies. Prognostic systems are also useful to compare clinical series and stratify severity in therapeutic trials. The multiple criteria of Ranson and Imrie predominate, but offer limited accuracy, involve delay, are cumbersome, and provide a one-off overall prediction. Internationally agreed definitions of complications demand accurate risk assessment for individual complications, while serial monitoring of severity is needed to assess progress and to detect subtle changes after therapeutic intervention. Laboratory methods now provide equal, or improved, accuracy and speed compared to traditional criteria, and may be repeated serially. Growing knowledge of the systemic inflammatory response syndrome (SIRS) and the availability of response modifiers suggests that inflammatory mediators may prove to be the most useful and accurate means of assessment of severity.

Acute Disease↗
PubMed1993

Impaired mononuclear phagocyte function in patients with severe acute pancreatitis: evidence from studies of plasma clearance of trypsin and monocyte phagocytosis.

Activated proteases in plasma are complexed by alpha 2-macroglobulin. Although the complexes retain peptidase activity, they are usually eliminated promptly by mononuclear phagocytes. In severe acute pancreatitis, almost 30% of plasma alpha 2-macroglobulin becomes complexed, suggesting impaired clearance. In the present study, plasma [methyl-14C]trypsin clearance and monocyte phagocytosis were investigated. Attacks complicated by major organ-system failure, pancreatic pseudocyst, abscess, or necrosis were graded severe (median Ranson score 5.5). Plasma [methyl-14C]trypsin half-life was significantly increased in severe attacks (N = 7, median 21.1 min), compared to mild attacks (N = 14, median 15.4 min, P < 0.05) and healthy controls (N = 4, median 10.8 min, P < 0.02). Monocyte phagocytosis was significantly lower in severe attacks (N = 9, median 3.6%) compared to mild attacks (N = 20, median 20.8%, P < 0.01) and healthy controls (N = 8, median 26.9%, P < 0.01). Plasma [methyl-14C]trypsin half-life and monocyte phagocytosis were significantly inversely correlated (r = -0.51, P < 0.01). Impaired clearance of circulating trypsin in acute pancreatitis is potentially deleterious but may be reversed by stimulating mononuclear phagocytes.

Acute Disease↗
PubMed1990

Dynamic contrast enhanced computed tomography: a precise technique for identifying and localising pancreatic necrosis.

OBJECTIVE: To evaluate dynamic contrast enhanced computed tomography for detecting and localising pancreatic necrosis in acute pancreatitis. DESIGN: Prospective evaluation with blind reporting of scans. SETTING: Single teaching hospital. PATIENTS: 60 Consecutive patients with acute pancreatitis suspected to have pancreatic necrosis because of major organ system failure (13); slow recovery five to seven days after admission with raised scores on the acute physiological and chronic health evaluation (APACHE-II) system (27); or findings on previous ultrasonography or computed tomography (20). MAIN OUTCOME MEASURE: Pancreatic necrosis proved histologically--that is, greater than 30 g necrotic tissue debrided at laparotomy (for life threatening sepsis or peritonitis) or necropsy. RESULTS: Dynamic computed tomography correctly localised pancreatic necrosis in 11 patients (confirmed at laparotomy in nine and at necropsy in two). Of nine patients with low enhancement of peripancreatic tissues alone, eight recovered after conservative management; necropsy confirmed viable pancreas and necrosis of peripancreatic fat in one patient. Of 40 patients with normal contrast enhancement, none required laparotomy to debride pancreatic necrosis. CONCLUSION: Dynamic contrast enhanced computed tomography seems to be a safe and accurate method of identifying and localising pancreatic and peripancreatic necrosis, which cannot be predicted accurately by conventional imaging techniques.

Acute Disease↗
PubMed1990

Proteolytic degradation of human recombinant proinsulin/insulin by sera from acute pancreatitis patients and complete inhibition by Eglin-C.

Sera from patients of biliary, alcoholic, and idiopathic acute pancreatitis with severity scored from 1 to 5 based on the Ranson criteria were tested for proinsulin/insulin degrading activity. Proinsulin degrading activity by normal controls was 8 +/- 4% as compared with 22-78 +/- 17% with a mean of 45% by the patient sera. An order of magnitude increase of proinsulin degrading activity was accompanied by an order of magnitude increase of immunoreactive pancreatic cationic trypsin(ogen) and (pro)elastase-2 as determined by radioimmunoassay with day 1 sera. Proinsulin degrading activity also showed a negative correlation with the clinical time course and dropped to normal by 6 days after admission. The decrease of proinsulin degrading activity was concomitant with a decrease of serum immunoreactive pancreatic serine proteases. High-performance liquid chromatography analysis of the proteolysis products showed the appearance of insulin and smaller peptides with no proinsulin conversion intermediates. Ninety to ninety-eight percent of proinsulin degrading activity was inhibited by anti-alpha 2-macroglobulin (alpha 2-M) antiserum, or (Ac)Eglin-C(J141), and 52% by an elastase and chymotrypsin-specific inhibitor, MeOSuc-Ala-Ala-Pro-boroVal-pinacol. E64c, TLCK, alpha 1-protease inhibitor (alpha 1-PI), or Trasylol inhibited proinsulin degrading activity by 10-17%, and anti-cathepsin B antiserum by 9%. The observed proinsulin degrading activity did not correlate with the Ranson's scores, age, sex, etiology, total serum immunoreactive insulin, calcium, albumin or alpha 2-M but had a negative correlation with serum alpha 1-PI (r = -0.55) and a positive correlation with serum esterase activity (r = .62).(ABSTRACT TRUNCATED AT 250 WORDS)

Humans↗
PubMed1989

APACHE-II score for assessment and monitoring of acute pancreatitis.

The value of the Acute Physiology and Chronic Health Enquiry (APACHE-II) score, the Simplified Acute Physiology score, and the Medical Research Council (MRC) sepsis score were compared with clinical assessment and Ranson and Imrie scores in the evaluation and monitoring of acute pancreatitis in 290 attacks. Attacks were graded mild (231) if uncomplicated, or severe (59) when major organ failure or a pancreatic collection occurred. Only APACHE-II scores were available at the time of admission; they correctly predicted outcome in 77% of attacks and identified 63% of severe attacks, compared with 44% achieved by clinical assessment. After 48 h, APACHE-II was most accurate, and correctly predicted outcome in 88% of attacks, compared with 69% for Ranson and 84% for Imrie scores. APACHE-II predicted 73% of pancreatic collections at 48 h, compared with 65% for Ranson and 58% for Imrie scores. In acute pancreatitis, APACHE-II may facilitate rapid selection of patients for intensive therapy or clinical trials, improve comparison between groups of patients, and indicate that a pancreatic collection is probable.

Abscess↗
PubMed1989

Debridement and closed cavity irrigation for the treatment of pancreatic necrosis.

Pancreatic and peripancreatic debridement combined with a closed cavity system of drainage was used to manage necrotic sequelae of severe acute pancreatitis in 14 patients. Intravenous contrast-enhanced computed tomography, or latterly incremental dynamic computed tomographic angiography, accurately detected and localized necrotic tissue. Operation was delayed where possible to permit demarcation of the necrotic area and the development of a 'capsule' of inflammatory tissue. A retrocolic route of access to the necrotic area was used in nine cases, and purpose-made silicone elastomer tubes with an outside diameter of 20 mm were positioned so that drainage was assisted by gravity when the patient was supine. The cavity was irrigated with saline (initially 2 litres daily), and in the last seven patients Trasylol was included in the irrigation fluid (5 x 10(6) kallidinogenase inactivator (KI) units/litre) for the first postoperative week. Three elderly patients died (mean age 72 years) but all patients aged less than 68 years survived. Planned reoperation was carried out in two patients, but further reoperations were not required in the remaining 11. Drainage tubes were removed when contrast studies showed the cavity to be small and superficial; the median duration of drainage was 28 days. Although sinograms demonstrated fistulae between cavity and small bowel (n = 4) or small bowel and colon (n = 2), no clinical problems resulted and all closed spontaneously. Closed drainage may be as effective as techniques of marsupialization, but avoids the need for frequent relaparotomy.

Acute Disease↗