Biomedical subjects
Publications and source records attributed to R C Russell.
We describe our initial experience with extracorporeal shock-wave lithotripsy, direct solvent dissolution with methyl tert-butyl ether and mechanical extraction, in 17 symptomatic patients without significant gall-bladder wall disease using existing criteria for selection. Extracorporeal shock-wave lithotripsy and mechanical extraction are promising techniques. Methyl tert-butyl ether therapy has been fraught with difficulty.
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The effect of hyperbaric oxygen (HBO) on axial pattern skin flap survival in male Wistar rats, when administered during and immediately following prolonged total flap ischemia, was evaluated. Eighty-one 3 x 6 cm rectangular epigastric skin flaps were elevated, and the inferior epigastric pedicle of each flap occluded for 8 hr. The animals were divided into a control and three other experimental groups: Control (n = 27) -8 hr flap ischemia, no HBO; Group (n = 21) - HBO therapy (100 percent O2--three 1.75 hr dives at 2.5 atm) during ischemia; Group 2 (n = 21) - HBO therapy (two 1.75 hr dives) following ischemia; Group 3 (n = 12) - HBO treatment during ischemia but with the flap contained in a metal-coated Mylar bag to prevent oxygen diffusion. The percentage of flap necrosis was calculated on postoperative day 6. Mean flap necrosis for controls was 28 percent (+/- 21 S.D.), while HBO treatment during ischemia or during reperfusion significantly reduced this necrosis to 9 percent (+/- 11) and 12 percent (+/- 14), respectively (p less than 0.01). The percentage of necrosis for Group 3, with the local with the local effect of HBO on the flap blocked by the diffusion barrier, was 5 percent (+/- 7), also significantly better than the controls (p less than 0.0005) but no different from the other two experimental groups. HBO treatment increases the percentage of axial pattern skin flap survival when administered during or immediately following total flap ischemia. The improved flap survival appears to be a systemic and not a local effect.
Seventeen consecutive patients with the sump syndrome were treated at the Middlesex Hospital between November 1983 and December 1987. Fifteen were treated primarily by endoscopic sphincterotomy and two primarily by resective surgery because of coincident severe painful chronic pancreatitis. Endoscopic sump clearance was successful in thirteen out of fifteen cases (87%) with no morbidity or mortality. The two endoscopic failures were managed surgically. Follow-up (mean 18 months; range 2-48 months) has shown complete resolution of symptoms in twelve (71%), with mild or moderate ongoing symptoms in the remaining five. All patients with ongoing symptoms after sump clearance had abnormal retrograde pancreatograms at the time of ERCP. Endoscopic sphincterotomy is the treatment of choice for the sump syndrome, with the possible exception of patients with coincident painful severe chronic pancreatitis, who may require pancreatic resection. Indeed, the sump may be a factor in the development and perpetuation of an obstructive chronic pancreatitis, and a trial of endoscopic clearance may be indicated even in these patients. The sump syndrome should no longer be regarded as a major long-term disadvantage of side-to-side biliary bypass, provided that the condition is considered early in those with compatible symptoms after biliary bypass, and appropriate investigation and treatment is instigated.
Endoscopic endoprosthesis insertion plays an increasingly important role in the palliation of jaundice in patients with unresectable malignant hilar biliary obstruction (HBO). Drainage of both obstructed lobes in Types II and III HBO is not necessary to achieve adequate palliation, providing 25% of the liver volume is drained by a single endoprosthesis. The anatomy of the main hepatic ducts suggests some benefit may accrue from preferential drainage of the left hepatic duct. We have reviewed a consecutive series of 151 patients with Type II and III HBO over a 4-year period to compare the outcome of endoprosthesis placement in either the right (RHD) or left (LHD) hepatic duct, to test this hypothesis. No significant difference was found in terms of successful drainage, complications, 30-day mortality, number of endoprosthesis changes and survival between patients with right system drainage compared with those with left sided drainage (chi 2-test and Mann Whitney U test). When dealing with a patient with a Type II or III HBO, we would recommend single endoscopic endoprosthesis insertion into the technically most accessible obstructed system. This would achieve adequate palliation in 84% of the patients.
A single-stage method of percutaneous removal of gallstones is presented which was adapted from our experience with percutaneous nephrolithotomy. It is performed under general anesthesia using ultrasound and fluoroscopic control. The overall success rate of 90 per cent and the fact that any stone, irrespective of its size or composition may be treated, firmly establishes this method as an important addition to the modern methods of treating gallstones.
A prolonged preoperative ischemic interval decreases the chances for successful replantation of an amputated limb. Skeletal muscle is especially sensitive to periods of prolonged ischemia. It is now hypothesized that significant tissue injury occurs during reperfusion, when oxygen-rich blood contacts anaerobic metabolites forming toxic oxygen free radicals. A replantation model, using the rabbit hind limb tibialis anterior muscle, was developed to assess muscle function and histological appearance following ischemic intervals of five and eight hours. Muscle strength five weeks after injury was used as a functional measurement of tissue damage. The effects of the superoxide free radical scavenger superoxide dismutase (SOD) and the hydroxyl radical scavenger dimethylsulfoxide (DMSO), administered systemically just before reperfusion, were studied. Muscle treated with SOD following five hours of ischemia had essentially normal strength and histological appearance; however, there was no protective effect after eight hours. DMSO treatment had no beneficial effects after five hours of ischemia, but after eight hours DMSO-treated muscle had significantly better function than untreated muscle. Histological examination confirmed the functional results. Clinical treatment of ischemic limbs with free radical scavengers before revascularization may aid in avoiding reperfusion injury and may improve survival and later muscle function.
Resection of cutaneous malignancies of the medial canthus and lower lid create challenging wound closure problems. The V-Y flap closure technique achieves wound closure using adjacent tissue while minimizing closure tension. Twenty-three patients underwent resection of basal cell carcinomas in these two anatomical regions. In 22 patients a single V-Y flap was used to close the defect. In 1 patient two flaps were used. There were 2 patients with transient ectropion. No tissue loss or other complications occurred.
The nose is a difficult anatomic region in which to close defects resulting from resection of cutaneous malignancies. The V-Y flap is a technique for advancing adjacent tissue, thereby achieving wound closure while minimizing tension. A total of 120 V-Y flaps were used to close 114 nasal defects. The average defect size was 13.5 x 11 mm. Partial flap loss occurred in five patients, with total flap loss in one. One wound infection and two hematomas occurred.
We describe the typical clinical and histological features of a case of giant proliferative pilar cyst which was complicated by severe iron deficiency anaemia. The condition, described by Cock in 1852 and eponymously known as Cock's peculiar tumour, is compared to giant proliferative pilar cyst. These entities are probably synonymous.
A patient with annular pancreas presenting with severe upper abdominal pain is discussed. Endoscopic retrograde cholangiopancreatography (ERCP) was diagnostic, with successful injection of major and minor papillae showing pancreas divisum, an annular duct emptying at the major papilla and changes of severe chronic pancreatitis in all duct systems. Pylorus preserving pancreatoduodenectomy gave complete pain relief. The annulus was shown immunohistochemically to be entirely of ventral gland origin. Chronic pancreatitis was histologically less severe in the dorsal gland. Antegrade dye injection with x-ray showed dorsal to ventral connection in the resected specimen.
One hundred and twenty seven patients were treated by nasobiliary drainage, or stenting, to prevent biliary obstruction after endoscopic failure to clear stones from the common bile duct. At presentation, 91 (72%) patients were jaundiced and 39 (31%) had cholangitis. Placement of either a nasobiliary drain or stent was successful in 124 (98%) patients. One hundred and twenty one (95%) patients were followed up. Clearance was ultimately achieved endoscopically in 52 and surgically in 25 patients after (mean) 2.4 months. Thirty day mortality was 3%. There were no complications of nasobiliary drainage, but two of 39 patients treated by temporary stents developed cholangitis, both successfully managed by endoscopic duct clearance. Forty two patients unfit for surgery or further endoscopic attempts at duct clearance were followed with stents in situ for a mean 15.9 months (range 2.5-37.5). Cholangitis developed in four patients and was successfully managed by stent change. These results indicate that longterm stenting can be useful for poor risk surgical patients and that nasobiliary drainage or temporary stenting permits further elective rather than urgent endoscopic or surgical treatment.
It is uncertain whether ERCP and associated procedures are more difficult when the papilla is inside or adjacent to a duodenal diverticulum. We have therefore reviewed the data from 2458 consecutive, prospectively reported ERCPs between November 1983 and March 1988. Three hundred and eight patients (12.5%) had periampullary diverticula and in 21 the papilla was located deep within the diverticulum of whom 227 had undergone endoscopic sphincterotomy (73.7%). Comparison was made with the 2150 patients without diverticula of whom 1223 (56.9%) had undergone sphincterotomy. The success rate of specific duct cannulation was 94.2% in the diverticulum group and 96.7% in those without diverticula (p less than 0.05). The overall success rate of endoscopic sphincterotomy was 95.2% in the diverticulum group, as compared with 98.0% in those without diverticula (p less than 0.05). The procedure related morbidity and mortality of sphincterotomy were 5.2%/0.9% and 4.0%/0.7% respectively (NS). If only those who had successful cholangiography were included there was no difference in sphincterotomy success between those with and without diverticula. The group of patients with papilla deep within diverticula had a slightly higher failure rate of pure endoscopic sphincterotomy (11.8% v 5.7%: NS) but did not have a higher complication rate. In the subgroup of patients with choledocholithiasis, duct clearance of stones was as successful after sphincterotomy in those with diverticula as in those without. Medium term complications (mean 26 months) occurred in 1.4% of patients with diverticula and in 0.7% of patients without diverticula. We conclude that diagnostic cholangiography is more difficult when the papilla is closely associated with a diverticulum but that if diagnostic cholangiography is obtained, sphincterotomy may be performed as successfully and as safely in those with or without diverticula.
The present case report describes a patient with an adrenal phaeochromocytoma who presented with infarction of the small intestine. The clinical features, diagnosis and treatment of this case are described. Despite excision of the tumour and necrotic intestine, this patient died in the postoperative period from overwhelming sepsis and multi-organ failure. Special reference is made to the delayed effects of established intestinal ischaemia on immune function and it is suggested that this was major contributory factor to the fatal outcome in the present case. The onset of gastro-intestinal symptoms in patients with phaeochromocytoma should suggest the possibility of imminent gut ischaemia and indicate the necessity for prompt excision of the tumour.
Aircraft disinsection with aerosol insecticides during flight has generally been held to be inadvisable because it was assumed that the insecticides would be rapidly removed by the cabin air-conditioning system. We have developed protocols to deliver 2% d-phenothrin at a dose of 35 g per 100 m3 in various aircraft, and trials undertaken on Boeing 747 and 767 aircraft showed that their air-conditioning systems do not preclude effective disinsection. Mortality levels of 100% for Culex quinquefasciatus and Musca domestica test insects were recorded under normal operating conditions during routine scheduled passenger flights with disinsection procedures undertaken at "blocks-away" or at "top-of-descent". As a result, "top-of-descent" disinsection has been introduced as the recommended procedure for aircraft landing in Australia.
Fingertip injuries are a very common problem that require precise wound care for optimal results. The special sensory receptor sites in the glabrous skin of the fingertip are uniquely adapted for digital proprioception and should be preserved whenever possible. The etiology of injury; the patient's age; the level, angle, and type of tip amputation; and the patient's anticipated hand use must all be considered when choosing the type of wound closure. The hand surgeon should select the method of repair that provides optimal hand function for each patient on an individual basis.
The typical hand deformity of Parkinsonism consists of metacarpophalangeal joint flexion and interphalangeal joint extension. An unusual case of a claw hand deformity in a patient with Parkinson's disease is described with hyperextension in the metacarpophalangeal joints and flexion in the interphalangeal joints. The operative technique to improve the marked limitation in hand function is described.
A percutaneous method was used to remove stones from otherwise normal gall bladders, as assessed by cholecystography and ultrasonography. The procedure was performed in a single stage under general anaesthesia, adopting the method and instruments used for one stage percutaneous nephrolithotomy. A Foley catheter was left in the gall bladder and the system checked with contrast at 10 days to ensure free drainage and exclude residual calculi. Seven out of eight patients had a successful percutaneous cholecystolithotomy. An adequate track could not be secured in one man; he had an uneventful cholecystectomy under the same anaesthetic. Follow up at three months of the seven patients showed no calculi and no complications. Percutaneous cholecystolithotomy may prove complementary to extracorporeal shockwave lithotripsy in patients in whom there is difficulty focusing the shock waves on the gall bladder or who have had incomplete disintegration of stones.