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Biomedical subjects

A J Donovan

Publications and source records attributed to A J Donovan.

At least 19 recordsLinked to original sources
PubMed1995

Choledochal cyst in the adult.

OBJECTIVE: The authors examined the natural history of choledochal cysts in adults treated surgically. BACKGROUND: An initial diagnosis of choledochal cyst is uncommon in adults. The recommended treatment is excision, rather than bypass, to achieve effective biliary drainage and because of the risk of cancer. METHODS: A retrospective study of 27 adult patients was completed to determine the frequency of anastomotic complications and the incidence of cancer. RESULTS: Fifteen patients were treated by cyst excision, and one developed an anastomotic stricture, treated by percutaneous dilation. Eight of 11 patients treated by cyst enterostomy required additional surgery for anastomotic revision. A final patient was treated by T-tube drainage. Five of the seven patients with cancer have died at a mean of 21.6 months. CONCLUSION: This experience documents the high incidence of cancer (26%), and high rate of stricture after cyst enterostomy (73%). The dismal prognosis once cancer has developed warrants cyst excision, even in asymptomatic patients, including those with prior cyst enterostomies.

Adolescent↗
PubMed1991

Pyogenic liver abscess. Modern treatment.

Historically, open surgical drainage has been the treatment of choice for pyogenic liver abscess. The records of 54 patients with pyogenic liver abscess were reviewed to determine whether earlier diagnosis with current imaging tests and definitive treatment with antibiotics, aspiration, or catheter drainage was an effective alternative to open drainage. Twenty-nine patients were treated with broad-spectrum antibiotics and diagnostic aspiration. Twenty-three (79%) recovered uneventfully, and six required catheter or operative drainage. Twenty-three patients (including five who failed aspiration) underwent drainage with percutaneously placed catheters. Nineteen (83%) recovered; four required open surgical drainage. Of seven patients who required open surgical drainage, six recovered. One (2%) of the 54 patients died following failed aspiration and catheter and surgical drainage. Four patients were successfully treated with antibiotics alone without aspiration. These results confirm that pyogenic liver abscess can be successfully treated with broad-spectrum antibiotics and aspiration or percutaneous catheter drainage. Open surgical drainage is reserved for patients in whom treatment fails or who require celiotomy for concurrent disease.

Adolescent↗
PubMed1991

Choledocholithiasis. Endoscopic sphincterotomy or common bile duct exploration.

A prospective randomized trial was conducted of preoperative endoscopic sphincterotomy and surgery (ES&S) or surgery alone (SA) in 52 patients with cholecystolithiasis and choledocholithiasis that were candidates for elective surgery. After ES&S 65% of patients were stone free. Eighty-eight per cent of patients with SA were stone free after surgery (p less than 0.05). Three patients in each group had residual stones at the completion of the operation. Five of these six had more than 20 common bile duct (CBD) stones. There was one episode of major hemorrhage in a patient in each group and no deaths. Costs were essentially equal for the individual patient with a successful ES as compared to SA. Societal costs of a program of preoperative endoscopic retrograde cholangiopancreatography and ES would be higher because of the cost of screening for patients with CBD stones. These results do not support preoperative ES as a technique for clearance of the CBD of stones on the basis of efficacy, morbidity rate, or cost.

Adult↗
PubMed1990

Bilateral breast cancer.

A second primary breast cancer in the opposite breast can be either synchronous or metachronous. The majority are metachronous. A woman who has had breast cancer has a fivefold increase in risk for a second breast cancer. Additional risk factors include multifocal cancer, lobular carcinoma in situ, and an original cancer at an early age with long survival. Lobular carcinoma in situ is predominantly a marker for the subsequent development of a second primary breast cancer. The incidence of synchronous bilateral cancer is approximately 1% to 2% and that of metachronous cancer 5% to 6%. The cancer can be invasive or noninvasive. Mammography has increased the number of synchronous cancers found but not the overall incidence. The incidence of invasive cancer detected by random biopsy of the opposite breast is not high enough to justify routine adoption of this procedure. The remaining breast must be followed for the remainder of the patient's life by physical examination and annual mammography. The treatment of the secondary primary breast cancer should be that appropriate for the stage of the disease. The prognosis for the woman with a second primary breast cancer is quite favorable and is dependent on the stage of both the first and the second cancer.

Breast Neoplasms↗
PubMed1989

Nonoperative treatment of perforated duodenal ulcer.

This report concerns 35 adult patients in whom perforation of a duodenal or prepyloric ulcer was treated nonoperatively between July 1979 and April 1988 at the Los Angeles County--University of Southern California Medical Center, Los Angeles. Each patient had pneumoperitoneum with clinical evidence of peritonitis, and a gastroduodenogram documented a sealed perforation. The ulcer was believed to be acute in 27 patients and chronic in 8. These 35 cases represent 12% of 294 cases of duodenal and prepyloric peptic ulcers with perforation treated during the same period. An intra-abdominal abscess developed in 1 of the 35 patients. Reperforation did not occur. The mortality rate for the 259 cases treated operatively during this period was 6.2%; the mortality rate of the 35 cases treated nonoperatively was 3%. Duodenal ulcer can be safely treated nonoperatively when a gastroduodenogram documents self-sealing.

Adult↗
PubMed1988

Hepatic trauma.

Two hundred thirty-three patients were operated on for hepatic trauma during a two-year period. There were 101 patients with stab wounds, 90 with gunshot wounds, and 42 with blunt trauma. There were 56 isolated liver injuries. Three hundred seventy-five associated injuries occurred among the remaining 177 patients. The majority of patients required only drainage. "Liver sutures" were employed in 66 patients. Only 18 patients required débridement, resection, or packing. Twenty-eight patients (12%) died. Perioperatively, 13 patients died of hemorrhage from the hepatic wound and from the associated major vascular injuries that were present in eight of the 13 cases. The remaining deaths were not primarily a consequence of the hepatic wound. Control of hemorrhage remains the dominant consideration in the treatment of major hepatic wounds.

Drainage↗
PubMed1988

Correction of hypothermia by continuous pleural perfusion.

Hypothermia to less than 30 degrees C is associated with significant harmful effects, including ventricular fibrillation. None of the currently used techniques for core rewarming is entirely satisfactory. Continuous perfusion of the pleural space with warm saline solution has been studied as a method of core rewarming. Pigs were cooled to 28 degrees to 30 degrees C. The pleural space was continuously perfused with fluid at a temperature of 42 degrees C. Five hypothermic control pigs did not achieve a temperature of 32 degrees C in 3 hours of spontaneous rewarming. The rise in 1 hour was 0.34 degrees C. In 10 pigs that underwent continuous pleural perfusion the temperature exceeded 32 degrees C in a mean time of 56 minutes. The rise in temperature in the first hour of rewarming was 5.05 degrees C. Continuous pleural perfusion is a rapid and effective technique for core rewarming of the hypothermic pig.

Animals↗
PubMed1987

Pylethrombosis. Serendipitous radiologic diagnosis.

Pylethrombosis is thrombosis of the portal vein or any of its branches. Five cases have been serendipitously detected, four by computed tomography and one by ultrasonography. Two patients had abdominal sepsis. A third patient had apparent acute cholecystitis with choledocholithiasis. The last two patients had a hypercoagulable state, mesenteric venous thrombosis, and enteric infarction that required resection. The newer diagnostic modalities of computed tomography and ultrasound may document unsuspected pylethrombosis. Surgery may be required because of signs of peritonitis, enteric ischemia, or unresolved sepsis. Anticoagulation is indicated for acute thrombosis of the portal or superior mesenteric veins to prevent further extension and enteric ischemia.

Adult↗
PubMed1987

Injuries of the duodenum.

The records of 115 patients with a duodenal injury have been reviewed. The majority of the patients (83 percent) were treated with primary repair of the injury. Twelve patients underwent duodenal diverticulization. The mortality rate in all 115 patients was 12 percent, in 105 patients who survived more than 48 hours 4 percent, and in 26 patients with pancreaticoduodenal injury 15 percent. Vascular injury was the major cause of early death. Enteric perforations were present in 75 percent of the patients with sepsis. The majority of patients with associated pancreatic injury had primary repair and did not have pancreaticoduodenal complications. Duodenal fistula continues to be a serious postoperative complication. Primary repair with drainage is the preferred treatment. Gastrostomy and feeding jejunostomy are useful adjuncts. A more complex operation should be reserved for a highly select group of patients with severe duodenal injury.

Adolescent↗
PubMed1985

Ruptured amebic liver abscess.

Fifteen cases of extrahepatic rupture of amebic liver abscess have been reviewed. Five patients had thoracic rupture and ten had intra-abdominal rupture. Celiotomies were performed in five patients, with a preoperative diagnosis of acute appendicitis with perforation in four patients and generalized peritonitis of unknown origin in one patient. All 15 patients were treated with amebicides, including three patients with documented free intraperitoneal perforation who were not treated surgically. Twelve patients recovered uneventfully. Two patients with thoracic rupture developed secondary bacterial complications and in one case of free intraperitoneal rupture, a mistaken diagnosis of ruptured pyogenic abscess was made. Amebicidal therapy was delayed for four days. The patient died of multisystem organ failure. Amebicidal therapy is effective in the treatment of both unruptured and extrahepatic rupture of amebic liver abscess. Surgery should be required only for secondary bacterial complications.

Adult↗
PubMed1985

Percutaneous angiographic embolization for hepatic arterial hemorrhage.

Eight cases of hepatic arterial bleeding are reported. Bleeding in five instances was consequent to trauma and was either persistent postoperative (three cases) or delayed with hemobilia (two cases). Bleeding in the other three cases was from rupture of a subcapsular hematoma of the liver, with spontaneous hepatic rupture of pregnancy (two cases) and metastatic melanoma (one case). Angiography demonstrated pseudoaneurysm in six cases, a hepatic artery to portal venous fistula in one case, and a subcapsular hematoma in the final case. Percutaneous angiographic embolization controlled bleeding in seven cases and was not feasible in one case with tortuosity of the celiac axis. Complications included hepatobiliary necrosis in one patient and subphrenic abscess in two patients. Percutaneous angiographic embolization can selectively occlude a branch of the hepatic artery and is effective in the control of hepatic arterial bleeding from a variety of causes.

Adult↗
PubMed1983

Abdominal colectomy for chronic encephalopathy due to portal-systemic shunt.

Chronic portal-systemic encephalopathy (CPSE) following portal-systemic shunts may be incapacitating and non-responsive to intensive medical management. Between 1960 and 1980, 12 patients with cirrhosis who were institutionalized with CPSE underwent colonic exclusion. Cirrhosis was due to alcohol in ten patients and to cryptogenic liver disease in two. Nine patients had previously undergone end-to-side portacaval shunts and two patients had had mesocaval shunts. One patient had a spontaneous shunt between splenic and renal veins. Ten patients underwent colectomy and ileosigmoidostomy; one had colectomy, ileostomy, and mucous fistula; and one had colonic bypass and ileosigmoidostomy. Four patients died postoperatively. Survivors were clinically improved and able to leave a closed institutional environment. Colectomy may be considered in disabling cases of CPSE unresponsive to medical therapy; it is a final effort at functional rehabilitation. Although mortality is high, improvement in functional status can be expected among survivors of the operation.

Adult↗
PubMed1983

Abdominal stab wound with omental evisceration.

Among 100 patients with omental evisceration due to abdominal stab wounds admitted consecutively to the Los Angeles County-University of Southern California Medical Center, Los Angeles, major intraperitoneal injuries occurred in 69 cases. These injuries involved the small bowel (28), large bowel (15), spleen (three), stomach (ten), liver (14), diaphragm (nine), and pancreas (four). The incidence of major visceral injury coincidental to stab wounds with omental evisceration supports a policy of routine exploratory celiotomy in cases of abdominal stab wounds with omental evisceration.

Abdominal Injuries↗
PubMed1982

Management of the transected pancreas following distal pancreatectomy.

Fifty-six patients are reported upon in whom distal pancreatectomy had been performed for pancreatic trauma with presumed major injury to the pancreatic ductal system. The transected pancreas was compressed with sutures in 27 patients and with a stapler in 29 patients. The postoperative morbidity was comparable in the two groups--three abscesses and four pancreatic fistulas with suture of the pancreas and three of each when the pancreas was stapled. Death was due to perioperative hemorrhage from associated injury in five patients and to severe neurologic damage in three patients. The mortality was 14 per cent.

Humans↗
PubMed1981

Synchronous anterior celiotomy and posterior drainage of pancreatic abscess.

Pancreatic abscess has been characterized by a high rate of reoperation for persistent sepsis and by a high mortality. Nine patients with pancreatic abscess have undergone synchronous anterior celiotomy and posterior drainage following resection of the 12th rib. Pancreatic abscess was secondary to acute pancreatitis in seven of the cases. In two cases, the combined procedure was a secondary operation to treat abscess that developed following surgery for pancreatic trauma. All of these nine patients survived. One patient required reoperation for drainage of a left retrocolic abscess. A synchronous approach permits adequate exploration of the abdomen, provides the exposure necessary to remove necrotic tissue, and allows dependent drainage of the left subphrenic space without fear of splenic, pancreatic, or vascular injury.

Abdomen↗
PubMed1981

Biliary lithiasis and helminthiasis.

The syndrome of Oriental cholangiohepatitis is characterized by helminthiasis, choledocholithiasis often without cholecystolithiasis, biliary duct stricture and hepatic abscess. The common duct stones are usually multiple, black and friable. Fourteen cases have been seen in recent immigrants to the United States. Thirteen patients had choledocholithiasis, and 1 had viable flukes in the ducts. Choledochoenterostomy is usually required because of multiple stones, including intrahepatic stones, or proven or presumed infestation with Clonorchis sinensis. The latter, the Chinese liver fluke, is an infestation for which medical therapy does not exist. Resection, particularly of the lateral segment of the left hepatic lobe, may be required in cases of abscess and stones associated with stricture of the left hepatic duct.

Adult↗
PubMed1981

Results of a 12-year randomized trial of portacaval shunt in patients with alcoholic liver disease and bleeding varices.

During a 7-yr period (1967-1974), 89 patients with alcoholic liver disease and at least one severe upper gastrointestinal hemorrhage thought to be from esophageal varices entered a randomized, controlled trial of medical therapy vs. end-to-side portacaval shunt. Follow-up continued to September, 1979, so that all surviving patients had at least 5 yr observation after randomization. Among 45 patients randomized to surgical therapy, 4 did not receive portacaval shunt, for various reasons. Among shunted patients there were 11 episodes of upper gastrointestinal bleeding, none fatal and none thought to be from esophageal varices. Thirty-seven percent of eligible patients have had moderate or severe hepatic encephalopathy ascribed to the shunt. Of 44 patients randomized to medical therapy, 7 eventually received portacaval shunt after multiple bleeding episodes. Since randomization there have been 190 episodes of bleeding requiring 589 transfusions and resulting in 23 deaths from bleeding or hepatic failure precipitated by bleeding. THere are 12 survivors in the surgically treated group and 8 in the group treated medically. Life-table analysis shows a small increase in survival in the surgically treated group throughout the study, which is not statistically significant. From our data, we could not identify risk factors that would improve the selection of patients for medical or surgical therapy.

Adult↗