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Biomedical subjects

R H Pearl

Publications and source records attributed to R H Pearl.

At least 19 recordsLinked to original sources
PubMed1997

Appendectomy. Improving care through quality improvement.

OBJECTIVE: To evaluate the practice of appendectomy in Department of Defense hospitals worldwide in a large-scale quality improvement initiative. DESIGN: Case series study. POPULATION AND SETTING: A total of 4950 consecutive nonincidental appendectomies performed in 147 Department of Defense hospitals worldwide during a 12-month period ending January 31, 1993. RESULTS: The mean age was 25.5 years, with 64% males and 36% females. The patients were assigned a diagnosis of normal appendix (negative appendectomy) in 632 cases (12.8%), acute appendicitis in 3286 cases (66.4%), and perforative appendicitis in 1032 cases (20.9%). The influence of inpatient and outpatient delays on perforation and negative appendectomy rates were studied. In at least 52% of all patients ultimately assigned a diagnosis of perforative appendicitis, the perforation occurred before the first outpatient contact with the health care system, and in at least 68% of all patients ultimately assigned the diagnosis of perforative appendicitis, the perforation occurred before surgical evaluation and admission. Neither outpatient delay in diagnosis nor inpatient delay in diagnosis and treatment was associated with a significant change in the rate of negative appendectomy. CONCLUSIONS: Perforation rates are determined predominantly by patient- and primary care-related factors over which surgeons have little control. Negative appendectomies are predominantly related to the wide overlap in presenting signs and symptoms between appendicitis and the diseases that most often mimic it but do not require operative intervention. Whereas studies of this type are useful for identifying potential problems at the health care system level, the relatively small number of appendectomies performed by each surgeon precludes analysis at the practitioner level.

Adolescent↗
PubMed1997

Single-stage repair of Hirschsprung's disease: a comparison of 109 patients over 5 years.

Current management of Hirschsprung's disease (HD) typically involves staged therapy, which necessitates multiple hospital admissions and associated costs. The authors therefore investigated the course and outcome of treating such children using a single-staged (SS) approach, and compared them with those treated via multiple-staged (MS) therapy. The cases of one hundred nine consecutive patients who presented with HD from 1991 to 1996 were reviewed. Four patients were excluded (two unrelated deaths, two with small intestinal aganglionosis). Twenty-one of the remaining 105 patients underwent SS repair. Both groups were similar in gender, age at diagnosis, and frequency of comorbidities. Repair was possible in 100% of the SS patients. Complications, including enterocolitis, occurred in 63% of patients, and did not significantly differ between groups. The outcome in SS patients was unaffected by whether the repair was performed before or after 30 days of life. The outcome was unaffected by operative weight in either group. By contrast, the number of hospital admissions and total length of stay was significantly higher in the MS group, which resulted in a twofold increase in total costs associated with MS repair compared with SS repair. These data indicate that primary repair of HD is efficacious (even in the newborn), with morbidity equal to MS repair, and requires fewer hospital admissions. The significant savings to the patient and the health care system suggest that SS repair may be an improved strategy for treating HD.

Anastomosis, Surgical↗
PubMed1997

Diagnosis and management of duodenal injuries in children.

Traumatic duodenal perforations in children pose a diagnostic and therapeutic challenge. To identify specific diagnostic criteria and define an optimal therapeutic protocol, we reviewed all duodenal injuries treated at our institution in the past 10 years. There were 14 hematomas and 13 perforations. The diagnosis was confirmed by computed tomography (CT), ultrasound scan (US), upper gastrointestinal contrast studies (UGI), or at laparotomy. The clinical findings and CT findings of the two groups were compared. Children with suspected duodenal hematomas were treated expectantly, and children with duodenal perforations were treated surgically. Twenty-five associated injuries (10 pancreatic) occurred in 19 children. Children with perforations had higher injury severity scores (ISS) (25 v 9), but the two groups could not be differentiated based on presenting signs, symptoms, or laboratory findings. CT findings of retroperitoneal air or contrast were seen in 9 of 9 perforations and in 0 of 10 hematomas. CT findings of intraabdominal or retroperitoneal fluid, mesenteric enhancement, and thickened duodenal wall did not differentiate the two groups. Duodenojejunostomy was performed in one patient, and primary repair was performed in 11 children who had perforation. In five children, duodenostomy tube drainage with feeding jejunostomy or gastrojejunostomy were added. Complications occurred in three of four children in the first 5 years of the study and in two of nine children in the last 5 years. The decreased morbidity rate correlated with reduced time to definitive therapy (28 v 7.8 hours). Duodenal fistulae resulted in three of seven children treated without duodenostomy tube drainage and zero of five treated with drainage. Enteral feeds resumed faster (average, 12 v 27 days) if repair of perforation was combined with feeding jejunostomy or pyloric exclusion and gastrojejunostomy. Children with duodenal hematoma resumed eating an average of 16 days after injury. Only one child required surgery for persistent obstruction. The findings of retroperitoneal air and contrast extravasation on CT accurately distinguish duodenal perforation from hematoma. Conservative management of hematoma is safe and effective. Primary repair of perforation with duodenal drainage results in fewer postoperative complications, and gastrojejunostomy or feeding jejunostomy shorten the time to resumption of feeds.

Child↗
PubMed1997

Appendectomy: a contemporary appraisal.

OBJECTIVE: The authors present an accurate and comprehensive snapshot of appendicitis and the practice of appendectomy in the 1990s. METHODS: Appendectomies were performed on 4950 patients in 147 Department of Defense hospitals worldwide over a 12-month period ending January 31, 1993. RESULTS: The median age was 23 years (range, 6 months to 82 years) with 64% males and 36% females. The patients were assigned a diagnosis of normal appendix in 632 (13%) cases, acute appendicitis in 3286 (66%) cases, and perforated appendicitis in 1032 (21%) cases. There were no differences in perforation and normal appendix rates between those operations performed in teaching hospitals versus community hospitals or between high-volume hospitals (> or = 100 appendectomies/year) versus low-volume hospitals. Both a preoperative temperature > or = 100.5 and a preoperative leukocyte count > or = 10,000 were incapable of discriminating between patients with appendicitis and those with a normal appendix. Multivariate analysis showed a significantly increased risk of perforation associated with age younger than or equal to 8 years (38% vs. 18%) and age older than or equal to 45 years (49% vs. 18%). Females had a significantly higher rate of normal appendices (19% vs. 9%) and a lower rate of perforation (18% vs. 23%). The complication rates to include reoperation and intraabdominal sepsis were markedly increased in those patients with perforation. There were four deaths in this series (0.08%). CONCLUSIONS: Despite a marked decline in associated mortality over the past 50 years, rates of perforation and negative appendectomy remain unchanged because they are influenced strongly by factors untouched by the intervening technologic advances.

Acute Disease↗
PubMed1996

Death and dollars: the cost of dying in the surgical intensive care unit.

INTRODUCTION: The effect of resuscitation status on the use of laboratory and radiologic studies was analyzed in patients at the Walter Reed Army Medical Center's Surgical Intensive Care Unit. METHODS: A retrospective assessment of laboratory and radiologic charges incurred during the last 48 hours of life by 81 patients who died in the Surgical Intensive Care Unit between 1990 and 1992 was performed. Data were analyzed after separation by patient's resuscitation status. Each patient was assigned a resuscitation category: no limitation, do not resuscitate (no CPR in event of arrest), or limited therapy (specific order limiting care or monitoring). RESULTS: There were 4,095 laboratory tests performed for a total charge of $191,247. Arterial blood gas testing accounted for over $75,000 of these charges. Resuscitation status significantly affected test frequency. CONCLUSIONS: During the last 48 hours of life in an intensive care unit, the use of laboratory tests and radiologic exams has a substantial effect on the cost of care and is modified by the patient's resuscitation status.

Adolescent↗
PubMed1995

Pediatric appendectomy.

PURPOSE: To define patterns of care and outcome for pediatric appendectomy. METHODS: A study was designed to evaluate all pediatric appendectomies performed in the 147 Department of Defense hospitals worldwide. Cases of nonincidental appendectomy were identified through discharge diagnoses and operative logs, and 98.6% of the charts were retrieved for review. All charts were abstracted, and data were entered into a 127-field database for analysis. RESULTS: Over a 12-month period, ending January 1993, appendectomy was performed on 1,366 pediatric patients in the Department of Defense hospital system. The patients' median age was 12 years (range, 6 months to 18 years); 59% were male. The diagnosis was normal appendix for 157 patients (12%), acute nonperforated appendicitis for 930 (68%), and perforated appendicitis for 279 (20%). Age < or = 8 years was predictive (P < .001) of a higher rate of perforated appendicitis (33% v 18%) but was not predictive of normal pathology (13% v 11%). Female gender was associated with a significantly higher rate of normal pathology (17% v 8%; P < .001) but not of perforation (18% v 22%). Temperature elevation and right lower quadrant pain and tenderness did not clinically distinguish between diagnostic groups. Sixty-two percent of patients with a normal appendix had a white blood cell count of more than 10,000/mm3, as did 91% of patients with acute or perforated appendicitis. Those with perforated appendicitis received pre- and postoperative antibiotics, primarily ampicillin/gentamicin/clindamycin or Flagyl (41%), cefoxitin (34%), or Unasyn (15%). In 77% of this subgroup, intraoperative cultures were positive, with isolates for Escherichia coli (76%) Enterococcus (30%), Bacteroides (24%), and Pseudomonas (20%) predominating. There were no deaths. Major complications occurred in 1.2% of patients with acute appendicitis and in 6.4% of those with perforated appendicitis; there were no major complications in the group with normal appendectomies. The hospitalization period was more than 7 days for 1.6%, 40%, and 3.8%, respectively. CONCLUSION: This large series, from a large number of hospitals, with multiple practitioners, can serve as a community standard for pediatric appendectomy in the 1990s.

Abdominal Abscess↗
PubMed1994

Selective digital enhancement of conventional film mammography.

Screening mammography continues to play a key role in the early diagnosis of non-palpable breast cancer. Approximately 5% of patients will have lesions on their mammograms that appear neither clearly benign nor malignant. The proper management of these patients is not well defined. In this study, the mammograms of 64 women who underwent breast biopsy were reviewed. After the initial review, the mammograms were reevaluated using a personal computer driven digital conversion and enhancement system. The majority of indeterminate lesions were assigned a determinate diagnosis by enhancing the areas of abnormality through enlargement, contrast adjustment, and brightness adjustment. The radiologists were able to maintain baseline sensitivity and specificity throughout this process. In contrast, enhancement of lesions initially assigned a diagnosis of characteristically benign or malignant demonstrated no advantage over plain film mammography. These findings suggest a role for the selective use of digital mammography and enhancement techniques.

Adult↗
PubMed1993

Primary mediastinal masses. A comparison of adult and pediatric populations.

Since 1944 62 pediatric patients with primary cysts and tumors of the mediastinum have been operated on at our institution. We compared this group with 195 adult patients with similar diagnoses who were operated on during this period. Comparisons were made with regard to histologic type, location, presenting symptoms, physical findings, and surgical complications. We found significant increases in the prevalence of lymphoma in adults (41/195 versus 4/62, p < 0.05) and of neurogenic tumors in children (21/62 versus 24/195, p < 0.05). There were no significant differences in the prevalence of thymic tumors (51/195 versus 22/62), germ cell tumors (24/195 versus 4/62), and cysts (32/195 versus 15/62). There was no difference in the prevalence of symptomatic patients (99/195 versus 36/62). The prevalence of malignancy has increased in both groups since 1970 (2/28 versus 16/34 in children, p < 0.01; and 14/56 versus 69/139 in adults, p < 0.05). This is attributed to a rise in the prevalence of malignant neurogenic tumors in children and to an increase in the prevalence of lymphomas in adults. Tumor size, location, and the presence of symptoms were predictive of malignancy in the adult population but not in the pediatric population. No difference existed in mortality and morbidity between the two groups. All three pediatric deaths were directly related to loss of airway control as a result of mass effect from the tumor. Definite differences exist between the adult and pediatric populations with regard to mediastinal tumors. These differences need to be considered carefully when evaluating and planning treatment for a child with a mediastinal mass.

Adolescent↗
PubMed1992

Vascular ring: does magnetic resonance imaging replace angiography?

The records of 21 patients who underwent operation for symptoms attributable to vascular ring were reviewed. The study covered 33 years, 1958 to 1991, and the mean follow-up was 6.8 years. The patients ranged from 7 days to 26 years old with a mean age of 2.9 years. Twenty patients were symptomatic. Symptoms were due to tracheal compression in 16 patients, esophageal compression in 2, and both causes in 2. During the first 30 years, chest roentgenography, barium swallow, and aortography constituted the diagnostic workup in the majority of the patients. During the last 3 years, magnetic resonance imaging replaced aortography. The surgical diagnosis included five variants of vascular ring. The surgical approach consisted of left thoracotomy in 19 patients and right thoracotomy in 2. These 2 had the diagnosis of right aortic arch with posterior left subclavian artery. In both instances, preoperative angiographic data determined the surgical approach. Barium swallow may be sufficient for the diagnosis of vascular ring; however, additional data are useful in determining the surgical approach. Magnetic resonance imaging can yield accurate data without subjecting the patient to the risks associated with angiography.

Adolescent↗
PubMed1992

Management of catastrophic neonatal midgut volvulus with a silo and second-look laparotomy.

The case of a neonate with midgut volvulus and severe intestinal ischemia extending from the ligament of Treitz to the midtransverse colon is presented. Management consisted of abdominal silo application at the initial exploration to obviate the adverse physiological consequences of increased intraabdominal pressure from reperfusion edema of the intestine. The majority of the intestine was salvaged, and a short segment of ileum was resected. This method of treatment resulted in optimal ventilatory status, renal function, and cardiac performance. The advantages of temporary prosthetic wound coverage in selected cases of midgut volvulus include greater physiologic stability through the avoidance of "intraabdominal hypertension" and the ability to monitor the status of the intestine at the bedside.

Duodenal Obstruction↗
PubMed1992

Perioperative complications of long-term central venous catheters in high-risk patients: predictors versus myths.

A prospective cohort of 126 patients having long-term central venous catheterization was collected over a 10-month period. The patients were preoperatively assessed for the following risk factors: previous catheter placement, an absolute neutrophil count less than 500/mm3, a platelet count less than 50,000/mm3, a BUN value greater than 60 mg/dL or a serum creatinine level greater than 2.5 mg/dL, a prothrombin time greater than 1.5 times control, recent sepsis, and a Western blot test positive for HIV. The incidence of perioperative complications was 23%. Complications included pneumothorax, arterial puncture, tunnel hematoma, unsuccessful initial placement, and reaction to local anesthesia or blood products. No single risk factor had any statistical significance in predicting a complication. In the subpopulation of patients having two or more risk factors, the complication rate was 50%, with the majority of these being failed placement attempts. We conclude that inserting a permanent central venous catheter is not a benign procedure, but it can be safely done in critically ill patients. Furthermore, evaluation of preoperative risk factors in candidates for catheterization can be helpful to the surgeon with respect to counseling and operative planning.

Blood Cell Count↗
PubMed1991

Modified Nissen fundoplication: improved results in high-risk children.

A modified Nissen fundoplication was performed in 29 children (26 neurologically impaired and 3 neurologically normal). The modifications to the Nissen 360 degrees wrap were: (1) deliberate crural repair with pledgets; (2) recreation of the angle of His; and (3) anchoring wrap to the diaphragm. Presenting complaints were respiratory in 66%, nutritional in 28%, and for prophylaxis in 2 patients requiring gastrostomy tubes. Prospective follow-up was obtained in 26 of 29 patients for an average of 19 months. Early postoperative complications occurred in 3 patients, none due to recurrent reflux. Six late deaths occurred due to neurological deterioration, pulmonary disease, and medication overdose. Barium swallows were obtained in 20 of 22 available patients postoperatively and all wraps were intraabdominal. We conclude that the modified Nissen prevents wrap herniation and improves postoperative results in the high-risk neurologically impaired child.

Child↗
PubMed1991

Small intestinal transplantation in nonhuman primates.

Small intestinal transplantation represents a potentially therapeutic procedure for individuals with short gut syndrome. The purpose of this study was to develop a model for small intestinal transplantation in primates that is: technically feasible without microsurgery; consistent in the prevention of allograft rejection; functional in terms of nutrient absorption; and compatible with harvest for multiple organ procurement. First, autotransplantations on four rhesus monkeys were performed in order to study a variety of harvesting techniques and vascular anastomoses. Then, a study was performed with 14 heterotopic allotransplants in 4 baboons and 10 rhesus primates. The successful donor model consisted of division of the pancreas, harvesting the small bowel with a superior mesenteric artery and portal vein pedicle. The allograft vascular pedicle was anastomosed to the recipient's common iliac vessels in end-to-side fashion. The graft was transplanted as an out-of-continuity loop, both ends being exteriorized as stomas providing access for absorption studies and biopsy. Three immunosuppressive regimens were tested: (1) cyclosporine A (CyA) 20 mg/kg/d, solumedrol (SML) 2 mg/kg/d, and graft irradiation (150 rad) (n = 4); (2) CyA 20 mg/kg/d and SML 2 mg/kg/d (n = 3); and (3) CyA 40 mg/kg/d, SML 2 mg/kg/d, and azathioprine 5 mg/kg/d (n = 3). There were 4 deaths due to technical error in the first 24 hours. Weekly graft biopsy, serum CyA levels, complete blood count, and automated 24-channel serum analysis were performed. Grafts surviving greater than 14 days underwent absorption study via luminal perfusion with sucrose, maltose, dextrose, Pregestimil, xylose, and cyclosporine.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1991

Operative strategy for recurrent laryngeal cleft: a case report and review of the literature.

A case is reported of recurrent laryngotracheoesophageal cleft following two attempted repairs. The anterior approach to the larynx and trachea provided excellent exposure for defining the extent of the recurrent cleft, and allowed precise anatomic repair. Neurovascular structures were easily avoided by this operative method. Of 170 clefts reported in the literature, 19 recurred necessitating reoperation. The anterior approach to the larynx and trachea is appropriate in recurrent clefts and may be preferable at the initial repair.

Abnormalities, Multiple↗
PubMed1990

Cyclic neutropenia with colonic perforation and nonhealing colocutaneous fistula.

Cyclic neutropenia is an hereditary disorder of white blood cells, characterized by profound neutropenic episodes approximately every three weeks. Septic complications are usually limited to cutaneous and oropharyngeal infections. A 4-year-old boy with known cyclic neutropenia was in shock with neutropenia, clostridial septicemia, and right lower quadrant peritonitis when he was admitted. At the time of laparotomy, inflammation of the cecum, with no gross perforation, was found; no resection or appendectomy was done. He subsequently developed a right lower quadrant abscess that was drained, resulting in a colocutaneous fistula. For the next 8 months his fistula persisted, with intermittent episodes of fever, increased fistula output, and abdominal pain during his neutropenic periods. Standard nonoperative approaches to healing the fistula failed (ie, elemental feeds, total parenteral nutrition, irrigations, antibiotics, and drains). Attempts to medically abolish his neutropenic episodes using lithium, gammaglobulin, and steroids also failed. Ultimately, he underwent an ileocecal resection with primary anastamosis; the operation was done immediately following a neutropenic episode, in order to allow adequate healing of his anastamosis before his next period of neutropenia. Postoperative course was satisfactory, and he remains well after 8 months follow-up. This case, and several similar previously reported cases, illustrate that cyclic neutropenia may present with serious surgical complications. They also underlines the important role that neutrophils play in the healing of enteric fistulae.

Agranulocytosis↗
PubMed1990

Complications of gastroesophageal antireflux surgery in neurologically impaired versus neurologically normal children.

Antireflux surgery was performed in 234 children over a 5-year period; 153 were neurologically impaired (NI) and 81 were neurologically normal (NN). Initial presentation, demographic data, and type of antireflux operation were similar in the two groups. Eighty-six percent of the NI group versus 30% of the NN group had gastrostomy tubes placed. The incidence of late postoperative complications was 26% in the NI group and 12% in the NN group (P less than .01). During the late postoperative period, NI children underwent reoperation four times as frequently as NN children (19% v 5%, respectively; P less than .01). Wrap herniation accounted for 38% of complications and 59% of reoperations in the late postoperative period. Mortality due to aspiration occurred in 9% of the NI group versus 1% of the NN group. Combined failure rate (reoperation plus aspiration-induced deaths) was 28% in NI and 6% in NN (P less than .01). We conclude that neurological status is the major predictor of operative success and that wrap herniation due to crural disruption is the most common cause of operative failure.

Adolescent↗
PubMed1989

Liver transplantation in children: the initial Toronto experience.

The Hospital for Sick Children's initial 2-year experience with pediatric liver transplantation is reviewed. Patients are divided into high- and low-risk groups according to certain criteria. The high-risk group includes patients under 10 kg in weight, those with extrahepatic biliary atresia (EHBA), those with portal vein atresia or thrombosis, and those in hepatic coma. All others were considered low risk. Twenty-nine patients were assessed for transplantation: 18 were transplanted and 6 (21% of total referred) died while on the waiting list. Eighteen patients received 23 transplants. Of the 18 recipients, nine had EHBA, four had fulminant hepatic failure, two had tyrosinemia, one had glycogen storage disease, one had Indian childhood cirrhosis, and one had idiopathic cirrhosis. Seven of the 13 patients in the high-risk group survived (55% survival) with 1 to 23 month follow-up. Survival was significantly higher (80%) in the low-risk group (P less than 0.05). Four patients were retransplanted and two survived. Early deaths occurred from prolonged warm ischemia, recurrent portal vein thrombosis, and brain death in a patient who had been transplanted in hepatic coma. Late deaths occurred from cytomegalovirus (CMV) disease (2 patients), acute rejection (1 patient), and myocardial infarction (1 patient). The incidence of primary nonfunction was 4.3% (1 of 23) and of arterial thrombosis was 13% (3 of 23). Survival in patients transplanted for EHBA (67%) was slightly higher than it was for the rest of the group, although not as good as it was in the low-risk group.(ABSTRACT TRUNCATED AT 250 WORDS)

Biliary Atresia↗