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Biomedical subjects

R B Adkins

Publications and source records attributed to R B Adkins.

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

An aggressive surgical approach to bile duct cancer.

Fifty-five patients with bile duct carcinoma have been treated at the Vanderbilt University, Metropolitan Nashville General, and Baptist Hospitals since 1957. Thirty-eight per cent (21) of the patients had tumors arising in the upper third of the bile duct; eight (15%) were in the middle third, and ten (18%) were in the lower third. In 12 instances, the malignant process involved both the middle and lower thirds of the bile duct, and in four cases, the extent of the tumor was too great to determine its origin. Most patients (49) presented with jaundice. Thirty (54%) also had pain, and 43 (24%) had experienced some weight loss. Fifteen had hepatomegaly, but only eight were found to have an enlarged gallbladder upon physical exam. Four patients (7%) had a positive history for hepatitis. Resection of the tumor was possible in 19 patients (35%). Decompressive procedures and biopsies were done in 25 of the others. Decompression was not possible in 11 patients. Survival for the 11 patients whose tumors were only biopsied averaged 4.6 months. Of the 25 patients who had palliative decompression, average survival has been 7.7 months. The 19 patients who had resection of their tumors survived an average of 2.08 years. Six of these patients are alive from 1-9 years post-diagnosis. Recently, a more aggressive surgical approach to bile duct carcinoma has been successful and has affected possible cure in ten patients of 19 in whom resection was possible and offered prolonged palliation to many of the other patients.

Adenoma, Bile Duct↗
PubMed1986

Dysphagia associated with an aortic arch anomaly in adults.

Aortic arch anomalies typically become evident in early childhood with clinical manifestations such as cyanosis and feeding problems. Although uncommon and therefore not often considered, this developmental defect can cause dysphagia in the adult. The double aortic arch is the most common vascular ring in infants. Less well-known vascular rings in the adult are a right aortic arch with constricting left ligamentum arteriosum and an aberrant right subclavian artery. Dysphagia is common secondary to the constriction of the esophagus. Two patients recently presented to the Metropolitan Nashville General Hospital with prolonged history of dysphagia. Studies included barium swallow and aortogram, which showed right aortic arch in both patients with constricting left ligamentum arteriosum. The treatment for these symptomatic anomalies was division and excision of the ligamentum arteriosum and freeing of the esophagus. A right aortic arch on the chest roentgenogram in a patient with dysphagia should suggest a vascular ring as the etiology. If this is suspected, diagnosis is easily made and surgical treatment is effective. The relevant embryology will be discussed.

Adult↗
PubMed1986

Renal vascular injuries.

Fifteen patients with injuries to the renal arteries and/or veins have been treated in the past ten years. Nine injuries were the result of gunshot wounds, and six were from blunt trauma. Twelve patients presented to the emergency department in shock; two of these did not have a palpable blood pressure. Time from admission to time of operation averaged 6.4 hr for patients with blunt trauma and 1.25 hr for patients with penetrating trauma. Seven patients had ten associated abdominal vascular injuries, and two patients had injuries to both the right renal artery and left renal vein. Associated nonvascular abdominal injuries were found in all 15 patients. Efforts were made to repair renal vascular injuries with suture or grafting of the injured vessel in eight cases (53%). These efforts were successful in four patients, but in four the repair failed and a nephrectomy could not be avoided. Two patients died in the operating room or immediately postop in spite of successful repair of their renovascular injury. One injured left renal vein was ligated and nephrectomy was not necessary. In five patients, ligation of the injured renal artery and nephrectomy were necessary. There were five deaths (33%). Three of the deaths occurred in the operating room and two were postoperative deaths. Only one of the patients who died had a renal vessel injury without other major vessels involved. He did, however, have serious liver and kidney injuries. Multiple associated vascular, nonvascular, and head injuries were present in all four of the other deaths. We have continued to take an aggressive approach to exploration, isolation of the injury, and repair of the vessel whenever possible if a renal vessel injury is suspected.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1985

The management of gastric ulcers. A current review.

In the past 10 years, 163 patients with documented gastric ulcers were treated at Vanderbilt University and Metropolitan Nashville General Hospitals. One hundred thirty-five were initially managed medically. Medical therapy was successful in 58 patients (43%) in this group. Twenty-eight (17%) patients required surgical treatment initially. An additional 77 patients (57%) became candidates for surgical management when their medical management failed. Of this group, 40 now have been surgically treated and 37 still have symptoms while on medical treatment. Three patients being treated for benign ulcers, two for as long as six years each, were found to have carcinoma of the stomach diagnosed by subsequent endoscopy and biopsy in one and by laparotomy with gastrectomy to include the ulcer in two. We consider subtotal gastrectomy or surgical resection of the antrum, including the ulcer site, to be the preferred surgical treatment for gastric ulcers, and this was done in 50 cases. Vagotomy was done in addition to the antrectomy in 31 of these, and in addition to the subtotal resection in 11. Two patients who had vagotomy and resection subsequently developed a marginal ulcer. One of these who had a subtotal resection and vagotomy healed with medical treatment. The one who had a vagotomy and antrectomy required a second vagotomy for a missed vagus nerve. Gastrointestinal endoscopy in the past 10 years has improved to the point that very few malignant ulcers are missed by endoscopic biopsy. Large ulcers, those that perforate or continue to bleed, and those that fail to heal on medical treatment for a maximum of 2 to 3 months should be submitted to an antrectomy that includes the ulcer. Vagotomy should be added in selected cases.

Adolescent↗
PubMed1985

Abdominal vascular injuries.

Treatment of major abdominal vascular injuries is a challenge. Since 1973, 93 patients have been treated at our institution for 147 abdominal vascular injuries. The majority of these injuries (67%) resulted from penetrating trauma in young men between 21 and 30 years of age. Upon admission 72% of the patients were in shock. Injured most frequently were the iliac vessels (36%) and the inferior vena cava (20%). Suture repair with preservation of function was possible in 61%; ligation of the damaged vessel was necessary in 24 cases (26%). Overall mortality was 29%. Military anti-shock (MAS) trousers were used in the management of ten patients who had an average admission systolic blood pressure of 52 mm Hg; 50% survived. In six cases of refractory hypotension or cardiac arrest, thoracotomy was done in the emergency room; mortality in this group was 100%. For some abdominal vascular injuries, ER thoracotomy has a very limited application. The key factors for increasing the survival rate in patients with major abdominal vascular injuries include rapid stabilization, reversal of hypotension (especially by the use of MAS trousers), and prevention of coagulopathy, combined with prompt surgical exploration and thoracotomy when indicated.

Abdomen↗
PubMed1985

Surgical management of esophageal achalasia.

Between 1970 and 1983, 46 patients were hospitalized in the Vanderbilt University Medical Center and the Metropolitan Nashville General Hospital for treatment of achalasia. All patients had been symptomatic for at least two years. Efforts were made initially to manage most of these patients (40) with periodic esophageal dilatation. This was successful in only six cases (15%). In four instances (10%), patients had esophageal perforation. Thirty patients have had esophagomyotomy (Heller procedure), and 14 of these had an associated antireflux procedure. Three had proximal gastric vagotomy for associated duodenal ulcer disease. Twenty-seven (90%) have had a good result, three died postoperatively, and two elderly patients had postoperative myocardial infarction. The other patient had sepsis after repair of a perforated esophagus. While periodic esophageal dilatation is necessary in patients who may not tolerate an operative procedure, most patients with achalasia are best treated with Heller esophagomyotomy.

Aged↗
PubMed1985

Results of an aggressive surgical approach to gastric carcinoma during a twenty-three-year period.

The early work of Dr. William Longmire with total gastrectomy for gastric carcinoma prompted us to initiate an aggressive surgical approach to gastric carcinoma in 1960: in curative resections radical total gastrectomy with hepaticoceliac-left gastric arterial node dissection was to be performed for tumors involving the entire stomach or upper two thirds and radical 80% to 90% subtotal gastrectomy with similar node dissection for tumors located in the antrum. During a 23-year period 213 patients with confirmed gastric carcinoma were studied. Celiotomy was performed in 192: advanced gastric cancer was found in 185 and seven had early gastric cancer. In only 80 patients could resections for "cure" be done. In 31 patients who underwent total or extended total gastrectomy the operative mortality rate was 9.6%, and life table survival curves show a better survival rate than in 49 patients treated by subtotal gastrectomy, with an operative mortality rate of 16.3%. The study shows the urgent need for diagnosis of early gastric cancer by gastroscopic screening of adults at risk and the meager salvage by radical resection in advanced disease.

Actuarial Analysis↗
PubMed1985

Pseudotumor of the lung.

Benign lung tumors in children are rare. An equally uncommon finding is the inflammatory pseudotumor, a lesion that is grossly similar to a tumor and yet cannot be histologically defined as a neoplasm. They have been called xanthomas, histiocytomas, solitary mast cell granulomas, and xanthogranulomas by various authors. There is a tendency to overtreat these lesions as if they were malignant. In previous reports, lobectomy has been the usual treatment for these tumors. If a pseudotumor is suspected at exploratory thoracotomy, a wedge resection and frozen section should be considered. When these benign lesions are easily accessible, they can be enucleated, leaving all of the normal pulmonary tissue intact without compromising cure.

Adolescent↗
PubMed1985

Recent experiences with duodenal trauma.

In a 10-year period ending December 1983, 56 patients with duodenal injuries were treated at Vanderbilt University and Metropolitan Nashville General Hospitals. Most injuries consisted of isolated duodenal lacerations or perforations (37), five patients had duodenal hematomas, and 14 patients had injuries involving the duodenum, pancreas, ampulla, and/or common bile duct. Most injuries were successfully managed with suture repair. The Whipple procedure was necessary in five cases. Overall morbidity was 39.2 per cent, but complications directly related to the duodenal injury occurred in only six patients (10.7%). Only three patients died (5.3%). Excellent results can be achieved even with extensive duodenal injuries by the use of careful debridement and primary closure. When injuries to the duodenum are associated with injury to the ampulla of Vater, the head of the pancreas, or the common bile duct, a Whipple procedure is usually necessary. It has not been necessary to employ duodenal bypass or diverticulization.

Abdominal Injuries↗
PubMed1985

Penetrating chest wall and thoracic injuries.

Two hundred seventy patients with penetrating chest wall and thoracic injuries were treated at the Metropolitan Nashville General Hospital in a 5.5-year period ending July 1982. Most (250) were males, and the average age was 29.3 years. One hundred thirty-four injuries were the result of gunshot wounds and 18 patients had sustained shotgun wounds. Stab wounds were the cause of injury in 117 patients. Most patients were successfully treated with closed tube thoracostomy. Twenty-five patients required emergency room thoracotomy, and 27 patients were stable enough to be transported to the operating room for thoracotomy and repair of injuries. Survival in the patients who had emergency room thoracotomy was 12 per cent and 78 percent in patients who had operating room thoracotomy. All but one of the patients who died following operating room thoracotomy died within 1 hour of admission. When thoracotomy is indicated, it frequently must be performed very soon after admission. The indications for emergency thoracotomy must be known and recognized early if it is to be an effective procedure.

Adult↗
PubMed1984

Barrett's esophagus. A surgical entity.

During a ten-year period, endoscopy demonstrated acid-peptic esophagitis in 439 patients. Forty of these patients (9.1%) had Barrett's esophagus. Adenocarcinoma was present in the columnar epithelium in 15 (37.5%) of the patients with Barrett's esophagus. Hiatal hernias, with symptoms of heartburn, dysphagia, stricture, and ulceration, were found in more than 75% of the patients with Barrett's esophagus. We developed a treatment algorithm. Patients with symptomatic reflux esophagitis should undergo endoscopy with biopsy. If Barrett's esophagus is diagnosed, an antireflux procedure should be performed, preferably a proximal gastric vagotomy with Nissen's fundoplication. Follow-up examination by endoscopy with biopsy and cytology should be performed every six months. Indications for early esophagectomy include progression of cellular dysplasia, carcinoma in situ, and a non-healing Barrett's ulcer following an antireflux procedure. Our data support an aggressive surgical treatment of patients with Barrett's esophagus.

Adenocarcinoma↗
PubMed1984

Primary malignant mediastinal tumors.

Thirty-eight patients with primary malignant mediastinal tumors of all cell types are the basis for this review. Eleven of these patients had germ cell tumors. Five germ cell tumors were seminomas, two were malignant teratomas, and two were endodermal sinus tumors. Mean survival for all patients with germ cell tumors was 3.3 years. Eight children had surgical excision of mediastinal neuroblastomas, and all but 1 are alive for a mean survival of 6.7 years. Seven patients had lymphoproliferative disorders; 6 of these patients had nodular sclerosing Hodgkin's disease, and 1 had lymphoblastic (thymic) lymphoma. Mean survival was 5.1 years. There were five carcinomas of various cell types and one angiopericytoma. None of the patients with these lesions survived more than 2 years. Four patients had thymoma with an average survival of 3.7 years. Two patients had carcinoid tumors of thymic origin; neither survived more than 1 year. In 1972, we reported 5-year disease-free survival of 26% in a series of patients with primary mediastinal tumors. Our experience since 1970 shows current survival of 47.3% and 5-year disease-free survival of 34.2%. We use combined methods of therapy, including aggressive surgical resection, combination chemotherapy, and often mediastinal irradiation for most types of mediastinal tumors. Primary mediastinal malignancies should be treated aggressively using a multidisciplinary approach, since many of these tumors are curable.

Adolescent↗
PubMed1984

Penetrating colon trauma.

Of 56 patients with penetrating colon injuries over 6 years, 15% underwent exteriorized repair, 21% received a colostomy, and 64% were treated with primary repair. Of the eight exteriorized repairs, four required conversion to colostomies. In the entire group of 12 colostomies, there were two deaths, four abscesses, and one empyema. Thirty-six patients (64%) underwent primary repair. In this group there was one superficial wound infection, one empyema, but no intra-abdominal abscesses. Eighty per cent had associated injuries. All laparotomy incisions in the primary repair group except two were closed primarily. Large amounts of saline irrigant were used in all cases. All patients received broad spectrum antibiotics pre- and postoperatively. Primary repair of colon injuries can be done safely in many cases. Proper attention must be given to the associated injuries, the patient's general condition, and the time interval between injury and repair. We now find few indications for exteriorization of injured colons. Colostomies are done if our criteria for safe primary repair are not fulfilled.

Adolescent↗
PubMed1984

Pulmonary dirofilariasis: a diagnostic challenge.

The canine heart worm, Dirofilaria immitis, can occasionally cause pulmonary granulomas in man. Fewer than 100 such cases have been reported in the United States, mostly from along the Atlantic Seaboard and Gulf Coast. None of these cases have been from the Mississippi Valley states. We have described a patient with a 14-year history of smoking, a patient in whom an enlarging pulmonary nodule was found. The resected nodule contained a filarial worm. This case illustrates the difficulty in distinguishing these lesions from neoplasms.

Animals↗
PubMed1984

Surgical procedures in patients aged 90 years and older.

During the past five years 75 patients aged 90 years or more had 85 major surgical procedures at the Metropolitan Nashville General and Vanderbilt University hospitals. The most common operation was exploratory laparotomy. The second was lower extremity amputation for peripheral vascular disease and/or gangrene. Fifty-seven percent had general endotracheal anesthesia. Associated medical problems were common, and included congestive heart failure (24%), hypertension (21%), diabetes mellitus (13%), chronic arrhythmias (9%), history of myocardial infarction (8%), and history of cerebrovascular accident (5%). Eleven patients (13.4%), six of whom had general anesthesia, died after operation. Of these, two had postoperative pneumonia, two did not recover from bowel perforation and peritonitis, one had a postoperative myocardial infarction, another had a cerebrovascular accident, and one had sepsis. One patient's sudden death was likely due to myocardial infarction or pulmonary embolus. The other three deaths occurred in patients with extensive carcinomas (gallbladder carcinoma in one and widely metastatic carcinoma of unknown origin in two). These three patients died of the disease for which they were operated upon when the operation failed to alter its course. When surgical procedures are necessary to prolong and/or improve the quality of life in elderly patients, these procedures may be done in most cases with acceptable results.

Aged↗
PubMed1984

Splenic trauma: a trial at selective management.

The experience with splenic trauma at the Metropolitan Nashville General Hospital and at Vanderbilt University Hospital between 1972 and 1983 is the subject of this report. Of 154 emergency cases involving splenic injury, 134 were due to blunt trauma, with 20 cases resulting from penetrating injury. In 124 patients, exploratory laparotomy was done immediately after resuscitation and evaluation. Splenectomy was done in 113 (92%) cases, and in ten cases the spleen was repaired. Thirty patients (19.4%) were initially managed by observation of vital signs, serial hematocrit determinations, and serial physical examination. Of these 30 patients, 21 (70%) required exploratory laparotomy for continued bleeding after observation of 12 hours to six days. Eighteen of this group had splenectomy, and three had splenorrhaphy. Nine (5.8% of the total and 30% of the observed group) were successfully managed nonoperatively. Complications were encountered in 53 of the total 154 cases. There were 19 deaths (12.3%), 11 of them from head injuries. Splenectomy should be done promptly in cases of concomitant splenic and cerebral injury and in patients with injury of multiple organ systems. Nonoperative management of suspected splenic injury should be reserved for patients in stable condition and with few if any associated injuries.

Accidents, Traffic↗
PubMed1984

Management of penetrating hepatic injury. A review of 102 consecutive patients.

The records of 102 consecutively treated patients with penetrating hepatic injuries from 1972 through 1982 were reviewed. Fifty-five patients (54%) sustained gunshot wounds and 47 (46%) sustained knife wounds. The mean age was 29 years (range 3-71); 83 per cent were men. Hypovolemic shock was present in 39 per cent of all the patients, and 74 patients (73%) required perioperative transfusions. Major associated injuries were present in 65 patients (64%) with 30 patients having two or more other injuries. All patients received preoperative and postoperative antibiotics and 88 per cent were treated with intraabdominal drains. Fifteen patients were managed with a tamponade technique using multiple Penrose drains within the injury tract. Six patients (5.9%) required hepatic resection. Major vascular injuries were present in ten cases, and seven of these patients survived. Hospital stay ranged from 4 to 60 days with a mean of 14 days. Postoperative complications occurred in 42 per cent of the patients with over one-third of the complications being pulmonary related. Mortality was 2.9 per cent and all three deaths were secondary to bleeding from severe liver and associated vascular injuries. The low incidence of hepatic resection and mortality in this series of patients is attributed to the conservative management of liver injuries, adequate drainage, the use of a tamponade technique with multiple Penrose drains for through-and-through liver injuries and the expeditious repair of the vascular injuries. This paper includes a detailed description of the tamponade technique.

Adolescent↗