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Biomedical subjects

C A Herbst

Publications and source records attributed to C A Herbst.

At least 19 recordsLinked to original sources
PubMed1996

The efficacy of percutaneous cholecystostomy in critically ill patients.

Percutaneous cholecystostomy (PC) has been proposed as a method of biliary decompression in critically ill patients with acute cholecystitis. We evaluated the efficacy of PC in this setting. The charts of 33 critically ill patients (mean age 52, range 5-87) who underwent PC for suspected acute cholecystitis were retrospectively examined. Univariate analysis was performed to identify which patients might benefit from PC. PC was technically successful in all patients with no direct mortality or major complications. Failure to improve within 24 hours was associated with increased mortality (P = 0.02). A total of 22/33 patients improved, 17/33 survived, and 8/33 required surgery. PC delayed definitive operation in two patients. Cholelithiasis was associated with surgical intervention (P = 0.01) but not increased mortality. Favorable prognosticators for survival included gallbladder dilatation (P = 0.01), pericholecystic fluid (P = 0.01), and absence of a pulmonary artery catheter (P = 0.02). Predictors of improvement included gallbladder nonvisualization on hepatobiliary scan (P = 0.047), positive bile cultures (P = 0.017), and initial drainage of < / = 100 cc (P = 0.009). Age, laboratory data, the use of total parenteral nutrition, and intubation did not predict outcome. Nine positive bile cultures prompted antibiotic changes in five cases. Finally, PC was less expensive than open cholecystostomy ($1620 versus $3155). PC is a safe, cost-effective, minimally invasive procedure that has diagnostic and therapeutic value in critically ill patients with acute cholecystitis. The involvement of a general surgeon is important to ensure that those patients who do not improve within 24 hours receive early surgical intervention and provide long-term definitive care for those patients with cholelithiasis.

Acute Disease↗
PubMed1994

Peristomal pyoderma gangrenosum and inflammatory bowel disease.

Pyoderma gangrenosum (PG) is a debilitating skin disease most often associated with inflammatory bowel disease and is a reportedly rare cause of peristomal ulceration. The lesions of PG rapidly evolve from small, erythematous pustules to deep, painful, pyogenic ulcers within hours to days of onset. Although the behavior and the appearance of the lesions of peristomal PG are diagnostic, a lack of familiarity with PG often leads to misdiagnosis and inappropriate therapy. This study reports four cases of peristomal PG and discusses the 20 previously reported cases in patients with inflammatory bowel disease. Seventy-five percent of patients were female and 67% had Crohn's disease. All patients had colitis, including all of the patients with Crohn's disease, 82% of whom had additional perineal complications. The diagnosis of peristomal PG was based on clinical appearance alone in 83% of cases. The onset of peristomal PG ranged from 2 weeks to 3 years following ostomy. The response to medical therapy was variable. All cases (17 of 17) treated with high-dose corticosteroids and local wound care responded, but five cases required additional therapy. No patient was successfully treated with stoma revision. Risk factors for the development of peristomal PG include Crohn's colitis, female gender, and perineal disease. While most patients respond well to systemic steroids and local wound care, up to one third of patients require long-term medical management.

Adolescent↗
PubMed1993

Laparoscopic cholecystectomy: comparison of university and community experience.

We compared the first year's experience in performing laparoscopic cholecystectomy in a university hospital and a community hospital to determine the impact of postgraduate surgical training on outcome. Laparoscopic cholecystectomy was attempted on 446 patients. The conversion rate to open cholecystectomy was 8.3% and did not differ between institutions. Surgical house staff performed 43% of the cases at the university hospital compared with 8% at the community hospital. The greater use of laser and cholangiograms resulted in significantly longer mean operative time at the university hospital (141 +/- 26 min) than at the community hospital (114 +/- 52 min). The overall complication rate did not differ significantly (p = 0.15). Complications included common duct injury (three cases), bile leak (five cases), bleeding or hematoma (six cases), epigastric artery hematoma (one case), and death (one case). Operative inexperience during this first year may be a major determinant for the complication rates at both hospitals. It is too early to determine the impact of graduate surgical education on complications. Intense education and supervised instruction is requisite to minimizing the morbidity associated with laparoscopic cholecystectomy regardless of whether it is performed at a university or community hospital.

Adolescent↗
PubMed1989

Leak after vertical banded gastroplasty.

We have reported the case of a morbidly obese patient who became gravely ill during the first day after vertical banded gastroplasty. The diagnosis of a leak from the stomach was established by a Gastrografin swallow, and ten additional operations were done before the patient was discharged on the 135th postoperative day.

Adult↗
PubMed1988

Leaks occurring after gastric bariatric operations.

A leak from the stomach is the most serious complication that occurs after a gastric bariatric operation. The experience with 19 leaks that occurred after 791 gastric bariatric operations performed at North Carolina Memorial Hospital from 1975 to 1986 is described. The incidence of leaks was higher (8.3%) after a second than after a first gastric bariatric operation (2.0%). Ten leaks were life threatening and nine were not. There were no deaths. The diagnosis was made on the basis of Gastrografin swallow in seven patients, clinical findings in six, oral dye studies in three, barium study, a sinogram, and operation in one patient each. Thirteen of 16 patients were operated on within 4 hours of the diagnosis of a leak. One patient with a life-threatening leak and two with non-life-threatening leaks were managed without operations. Three patients were discharged after uncomplicated courses and readmitted, and the diagnosis of a leak was established. To minimize morbidity and mortality related to a leak, it is imperative to (1) recognize that a leak can occur after any gastric bariatric operation, (2) perform a Gastrografin swallow when a leak is suspected, and (3) operate on the patient if the Gastrografin swallow is positive or if the clinical findings suggest a leak.

Adult↗
PubMed1987

Cholecystectomy in morbidly obese patients.

Indications for performing cholecystectomy simultaneously with a gastric bariatric operation remain controversial. The extremes are to always perform cholecystectomy or to perform cholecystectomy only when there are palpable stones or the gallbladder is grossly diseased. Since 1975, 136 cholecystectomies have been performed simultaneously in 724 patients who had a gastric bariatric operation. Cholecystectomy had been performed before the bariatric operation in 120 and was required later in 18 patients. The clinical records, anesthesia, pathology, and operative reports provide the data for this study. Simultaneous cholecystectomy was done through the vertical midline incision used for gastric bariatric operation. No patients had the gallbladder bed closed or were drained. Operative cholangiogram were not performed because this procedure would have been difficult and significantly prolonged because of the obesity. No patients have developed postoperative choledocholithiasis. One patient developed a complication related to cholecystectomy, a common bile duct stricture. The length of the operation and the postoperative hospitalization with and without simultaneous cholecystectomy were compared. The results of intraoperative ultrasound studies performed upon these patients are described and discussed. It is concluded that cholecystectomy should be performed simultaneously with all gastric bariatric operations when there is gross or echogenic evidence of gallbladder disease. Cholecystectomy does not significantly prolong or complicate the gastric bariatric operation.

Adult↗
PubMed1985

Effect of proximal transposition of the ileum on mucosal growth and enzyme activity in orally nourished rats.

To determine whether exposure to proximal intestinal contents per se is an adequate stimulus for ileal adaptation of the magnitude seen after jejunectomy, rats were prepared by transposing 30 cm of distal ileum to the duodenojejunal junction or by sham operation. One month after surgery, mucosal mass (wet weight, protein content, and DNA content) and digestive enzyme activities were measured in segments of small intestine and compared between the groups. Measurements of mucosal mass in transposed ileum more than doubled those in control jejunum (p less than 0.001). Mean enzyme activities/cm bowel length in transposed ileum approached or surpassed measurements in control jejunum. In contrast to the other enzymes studied, mean sucrase specific activities were similar in transposed ileum and control jejunum, values fivefold greater than that of control ileum (p less than 0.002). We conclude that exposure of ileum to proximal intestinal contents reproduces the adaptive response that follows jejunectomy, without requiring short bowel. Sucrase responds to this exposure in a unique fashion.

Animals↗
PubMed1985

Complications requiring operative intervention after gastric bariatric surgery.

In a series of 565 morbidly obese patients having one of five gastric bariatric procedures done at North Carolina Memorial Hospital between May 1975 and December 1982, 55 patients had 58 complications requiring reoperation. These complications included a leak from the stomach or anastomosis, stomal obstruction, and subphrenic abscess. Weight loss after vertical banded gastroplasty appears to be comparable to that following gastric bypass with Roux-en-Y gastrojejunostomy. The complication rate of vertical banded gastroplasty is the lowest of the gastric obstructive operations we have done.

Bile Reflux↗
PubMed1985

Morbid obesity. Second gastric operations for poor weight loss.

This is a report of a clinical investigation of weight gain occurring after initial good weight loss following an operation performed to treat morbid obesity. The reasons for weight gain or poor weight loss after the first operation, the indications for a second operation, and the effectiveness and complications of four different "second" operations were examined. Thirty-five patients who were weight loss failures, a subgroup of 556 patients upon whom one of five bariatric operations had been performed, provided the clinical material for this investigation. The findings indicate that technical and nontechnical patient factors are responsible for the failure of the initial bariatric operation. The most effective second operation to treat weight loss failures was gastric bypass with Roux-en-Y gastrojejunostomy (GBRY). More difficult to perform than when done as the first bariatric operation, GBRY when done as a second operation is associated with a higher complication rate.

Adolescent↗
PubMed1985

The use of barium enema in the evaluation of patients with possible appendicitis.

Patients with right lower quadrant pain and possible appendicitis may present a difficult diagnostic dilemma to the surgeon. Barium enema has been used as an adjunctive test in the evaluation of patients with right lower quadrant pain in whom the diagnosis is unclear. The authors retrospectively reviewed their experience with 33 patients to determine the value of barium enema. The average age was 32 years (range, 2-89 years). Twenty-five patients had nonfilling of the appendix; nine of these patients had a mass effect on the cecum. Three patients had partial filling of the appendix and five patients had a normally filled appendix. Of the 16 patients who had nonfilling of the appendix without a filling defect of the cecum, 14 patients underwent operation. Eleven patients had appendicitis and three patients had a normal appendix. Two patients with nonfilling did not undergo operation and did well. All patients with a filling defect of the cecum on barium enema had appendicitis. All patients with partial filling of the appendix had appendicitis. Of five patients with normal appendices on barium enema, one patient had a diverticular abscess and underwent operation, and another patient had Meckel's diverticulitis which was excised. Barium enema can provide information to aid in the management of patients in whom the diagnosis of appendicitis is not clear. It can prevent unnecessary operation in some, and assist in earlier operation in others.

Adolescent↗
PubMed1984

Cost effectiveness of postoperative carcinoembryonic antigen monitoring in colorectal cancer.

Serial monitoring of carcinoembryonic antigen (CEA) has been thought to provide early indication of recurrent cancer in individuals who have undergone curative resection. The current study was designed to assess the costs associated with CEA monitoring. Costs included CEA determinations, other evaluative tests prompted by abnormal CEA values and hospital/surgical costs in patients undergoing "second-look" procedures. The authors estimated that the cost per resectable tumor was $24,779; but, under optimal circumstances, it might be as low as $10,446. The most important factors were the percentage of recurrent tumors and the proportion of these that were resectable. It proved slightly more efficient to limit the preoperative workup rather than to decrease the frequency of CEA determinations. The true benefits of CEA initiated second-look surgery in terms of prolonged survival remain unknown. More clinical experience is needed to better understand these benefits.

Carcinoembryonic Antigen↗
PubMed1984

Mallory-Weiss syndrome in a 10-month-old infant requiring surgery.

Mallory-Weiss syndrome is infrequent in children. Intractable hemorrhage requiring surgery has been reported in only one 6-year-old child in the English literature. We present a case of intractable hemorrhage from a Mallory-Weiss lesion in a 10-month-old infant requiring surgery. The incidence, etiology, diagnosis, and treatment of Mallory-Weiss syndrome in children is discussed in relation to this case.

Age Factors↗
PubMed1984

Effect of removal of pancreaticobiliary secretions on adaptation to short bowel in orally nourished rats.

To evaluate the need for intraluminal pancreaticobiliary secretions for mucosal adaptation in animals with short bowel, groups of paired rats were prepared with: 1) normal bowel length, 2) 60% proximal small bowel bypass, and 3) similar bypass of distal bowel. One animal in each pair underwent operative diversion of pancreaticobiliary secretions to distal (group 1) or bypassed intestine (groups 2 and 3). Rats were fed an elemental diet and killed 1 month later. Mucosal wet weight, protein content, and DNA content were measured in comparable segments of proximal jejunum and mid-small bowel. Within each group the patterns of response of the three measures of mucosal mass were similar. Group 1: removal of secretions was associated with a 20 to 30% increase in mass in both segments. Group 2: after proximal bypass, mass doubled in mid-small bowel (in continuity) whether or not pancreaticobiliary secretions were removed. Group 3: after distal bypass, no change in mass was apparent in the jejunum even with removal of secretions. We conclude that intraluminal pancreaticobiliary secretions are not required for maintenance of mucosal mass or adaptation to short bowel in animals fed an elemental diet.

Animals↗
PubMed1984

Intraoperative ultrasonography evaluation of the gallbladder in morbidly obese patients.

Intraoperative ultrasound evaluation of the gallbladder was performed in 55 morbidly obese patients undergoing gastric bariatric surgery. Cholecystectomy was performed in the presence of any physical or ultrasonographic abnormality. Eighteen patients (33%) had cholecystectomy. Nine patients had palpable gallbladder disease confirmed by ultrasound. Nine patients had abnormalities detected by ultrasonography only. There was no false-negative ultrasonographic exam compared to physical exam. Pathologically, all specimens but one showed evidence of disease, thus there was a false-positive incidence of 1.8%. None of the 37 patients with normal physical and ultrasonographic examination have returned with gallbladder disease following the bariatric surgery. Intraoperative ultrasonography shows promise in detecting nonpalpable gallbladder disease and decreasing the incidence of delayed cholecystectomy.

Cholecystectomy↗