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Biomedical subjects

D L Bouwman

Publications and source records attributed to D L Bouwman.

At least 19 recordsLinked to original sources
PubMed1996

Thermostability of purified human pancreatic alpha-amylase is increased by the combination of Ca2+ and human serum albumin.

Pancreatic fluid from a patient with a post operative pancreatic fistula was used to isolate human alpha-amylase by means of acarbose affinity chromatography. Amylase thermostability was measured in 4 solutions: (1) EDTA-dialyzed; (2) dialyzed solution plus 0.15 mmol/l (1.0 g/dl) human serum albumin; (3) dialyzed solution plus 0.25 mmol/l (1.0 mg/dl) calcium ions; and (4) dialyzed solution with both human serum albumin and calcium ions. Amylase activity was measured at predetermined times in samples heated to 60 degrees C. Thermostability was characterized by t1/2, the time to 50% initial amylase enzyme activity. In the dialyzed solution t1/2 was 0.75 +/- 0.19 min. This rose to 1.62 +/- 0.34 min with added human serum albumin, and to 8.24 +/- 0.13 min with added calcium ions. The combination of human serum albumin and calcium ions resulted in a synergistic increase of t1/2 to 180 +/- 26 min. These findings support our contention that human serum albumin, calcium ions and possibly other body fluid constituents must be considered in any utility involving amylase thermostability as a clinically relevant diagnostic marker.

Calcium↗
PubMed1995

Pseudocysts and pseudoaneurysms: surgical strategy.

Eight patients over an 8-year period required operation for spontaneous hemorrhage as a complication of a pancreatic pseudocyst. Three patients presented with abdominal pain or jaundice and bled in hospital while undergoing work-up. Four patients were admitted with upper gastrointestinal bleeding and one with intraperitoneal bleeding. Five patients were managed by pancreatic resection (two of the head and three of the tail) and three were managed by arterial ligation and internal drainage. There was one death (mortality rate, 12.5%). The first four patients in the series had their operations delayed secondary to a perceived need for further work-up or an inability to make an exact diagnosis of the bleeding site. All rebled, necessitating an emergency operation. The last four patients underwent an expedited workup and operation. Successful treatment of bleeding pancreatic pseudocysts requires good surgical judgment, especially when nonoperative methods fail or aren't applicable. The risk of recurrent hemorrhage is high, suggesting the need for immediate intervention once the diagnosis is made. Resection provides definitive control, although selected patients with easily accessible vessels may be managed more conservatively with ligation and drainage.

Adult↗
PubMed1994

Total abdominal colectomy: conditions defining outcome.

Published conclusions that total abdominal colectomy is a safe procedure need to be qualified by analysis of specific risk groups. We reviewed the records of 87 consecutive patients undergoing total abdominal colectomy at our institution to determine the factors affecting morbidity and mortality. Underlying disease and urgency of operation were the primary determinants of outcome. Mortality was 5.9 per cent in the patient groups who had the procedure done non-emergently or for bleeding when transfusion requirements were less than 10 units. Mortality was 10-fold higher (55.6%) in the groups where the procedure was done either as an emergency for non-hemorrhagic reasons or when perioperative transfusion requirements reached 10 units (P < 0.001). Morbidity followed the same distribution. Death resulted primarily from shock, myocardial infarction, or sepsis from an anastomotic leak. Limiting transfusion needs to less than 10 units, by either more aggressive evaluation or earlier operation, and more liberal use of ileostomy were the only maneuvers identified that may decrease risk in the emergency setting. Elective operation before complications arise will likely result in improvement in morbidity and mortality rates.

Adolescent↗
PubMed1994

Bleeding gastroduodenal ulcers: improved outcome from a unified surgical approach.

We have adopted a uniform, aggressive approach to the management of upper gastrointestinal hemorrhage. Our protocol consists of admission to a surgical service, endoscopy within 24 hours, and liberal use of intensive care monitoring. Urgent or emergency surgery is recommended for the following criteria: 1) presence of shock upon admission; 2) resuscitation requirements of greater than 4 units of blood; 3) age 65 years or older; 4) ulcer size greater than 2 cm or with stigmata of recent hemorrhage; or 5) history of a previous admission for an ulcer complication. During the period 1986-1990, 66 patients met the criteria for operation. There were 45 males and 21 females with an average age of 53.5 years (range, 29-84). Thirty-seven bled from a gastric ulcer and 29 from a duodenal ulcer. They were transfused an average of 5.0 units of blood (range, 0-13). There were no hospital deaths, but 11 patients (16.7%) had 12 postoperative complications. We conclude that a unified, single team approach to gastroduodenal hemorrhage with expedited work-up and early operation prevents death from this treatable condition.

Adult↗
PubMed1993

The management of unexpected findings at surgery.

The improved accuracy of noninvasive scanning devices has led to a decrease in unexpected findings. Nevertheless, the surgeon still may encounter unsuspected diseases during abdominal exploration. A logical approach to these problems is outlined in this article.

Abdomen↗
PubMed1991

Morbidity and mortality following total abdominal colectomy for massive lower gastrointestinal bleeding.

During the period of 1980 to 1986, 49 total abdominal colectomies were performed at the authors' institution for lower gastrointestinal bleeding. The overall mortality was 13 of 49 (27%). In the elective/urgent group, mortality was one of 14 (7%); in the emergency with ileostomy group it was two of two (100%); and in the emergency with anastomosis group it was ten of 33 (30%). Morbidity and mortality in this latter group were affected by age [mortality three of 15 (21%) for age less than 70 vs seven of 18 (37%) for age greater than or equal to 70] and the number of units of blood needed preoperatively and intraoperatively. There was no effect on outcome from type of anastomosis (stapled vs hand-sewn), choice of antibiotics, degree of underlying illness, or day of operation following admission. Thirteen patients had less than 10 units of blood transfused; one (7%) died and there was one complication. Conversely, 20 patients had ten or more blood transfusions and nine (45%) died (P = 0.05 vs former group). This latter group also had 16 major complications, including five anastomotic leaks, three intra-abdominal abscesses, and three myocardial infarctions. Total abdominal colectomy when done as an emergency for colonic hemorrhage is associated with excessive morbidity and mortality rates. An important factor contributing to morbidity and mortality that may be controllable is the amount of blood loss. Should total abdominal colectomy be the surgeon's operation of choice, it should be performed prior to 10 units of blood being needed. If this limit is passed, strong consideration should be given to performance of an ileostomy.

Age Factors↗
PubMed1990

The impact of technology on the management of pancreatic pseudocyst. Fifth annual Samuel Jason Mixter Lecture.

The records of 299 patients with 357 admissions for pancreatic pseudocysts seen between 1960 and 1989 were studied; 233 patients underwent operation. The natural history of pancreatic pseudocysts has been clarified by newer technology, such as ultrasonography, computer tomography, amylase isoenzyme measurements, and endoscopic retrograde cholangiopancreatography. All have influenced diagnosis, nonoperative management, and surgical operation. Differences between pancreatic pseudocysts associated with acute pancreatitis in contrast with chronic pancreatitis, and the complications of obstruction, hemorrhage, rupture, pancreatic ascites, infection, and jaundice can now be more rationally treated. Pancreatic pseudocysts and pancreatic ductal changes are now revealed earlier, especially by endoscopic retrograde cholangiopancreatography. Paradoxically, this information has encouraged nonoperative conservative therapy and also larger operations, eg, resection and adjunctive pancreaticojejunostomy. Partial resection of the pancreas together with the pancreatic pseudocysts was performed in 58 (25%) of the 233 patients. Recent technology permits cautious exploration of selective pancreatic pseudocyst drainage percutaneously or transgastroduodenally avoiding laparotomy.

Adult↗
PubMed1990

Alternatives in the surgical management of in situ breast cancer. A meta-analysis of outcome.

The surgical management of lobular carcinoma in situ (LCIS) and ductal carcinoma in situ (DCIS) remains controversial. For in situ breast cancer local excision (LE), local excision and radiation therapy (LERT) and mastectomy (MAST) have all been advocated. A search of the English literature found 13 reports concerning the surgical management of LCIS and 12 reports concerning the management of DCIS. The data were combined in a meta-analysis of outcome. As expected, recurrence rates following LE with both LCIS 8.4%) and DCIS (17%) are high. However,the overall mortality following mastectomy for recurrence, LCIS (2.8%) and DCIS (2.3%) does not differ statistically from those treated initially with mastectomy for LCIS (0.9%) and DCIS (1.7%). We conclude from these data that local recurrence after breast conserving procedures for in situ breast cancer does not carry an ominous prognosis. This knowledge should aid in planning individual therapy.

Breast Neoplasms↗
PubMed1989

Percutaneous endoscopic gastrostomy. New technique--old complications.

Early reports support the percutaneous endoscopic gastrostomy (PEG) as an alternative to traditional gastrostomy with lower cost, greater ease of placement, and low morbidity and mortality. The authors' bias has been to attempt PEG on nearly all patients referred to gastrostomy tube prior to performing open gastrostomy. In this light, we reviewed our 32 month experience of 115 PEG placements in 112 adult patients, with a mean follow-up of 59.4 days. Placement was unsuccessful in ten per cent of patients and difficult in another six per cent. Minor postoperative complications not requiring intervention occurred in 9.5 per cent of patients, and major complications in 20 per cent. Infection was the most common postoperative problem. Thirty day mortality was 24 per cent. No patient died as a direct result of the procedure. The ten per cent failure rate is a consequence of attempting PEG as the initial procedure in greater than 90 per cent of patients. PEG can be employed as an initial procedure in even the sickest of patients with a high rate of success, and morbidity comparable to open gastrostomy. This knowledge allows early PEG placement in all types of patients, thereby facilitating their transfer to a non-acute care environment.

Enteral Nutrition↗
PubMed1989

Peritoneovenous shunt (PVS) for malignant ascites. An analysis of outcome.

Fifty cases of malignant ascites were studied to determine what factors influenced outcome after peritoneovenous shunt. There were 36 women and 14 men. The five most common tumor types were colon, breast, gastric, pancreatic, and unspecified adenocarcinoma. Multivariate analysis between those patients surviving longer than 7 weeks (n = 20) and those who died in less than 7 weeks (n = 30) showed that women did uniformly better than men, even excluding the "female malignancies" (P less than 0.01). An elevated white blood cell count (WBC) and low platelets also were strong predictors of poor outcome (P less than 0.5 for difference in means between the two groups). Patients with pancreatic cancer and ascites fared poorly (80% mortality by 7 weeks) as did those with colon cancer (73% mortality by 7 weeks). By contrast, 50 per cent of the patients with breast and gastric cancer lived more than 7 weeks. Twelve patients had a LaVeen shunt placed, compared with 38 who had a Denver shunt. Fifty per cent of the La Veen shunts failed, with a mean time to failure of 69 days (P less than 0.01). Shunt failure, however, had no influence on overall survival.

Adenocarcinoma↗
PubMed1988

Colon cancer: surgical therapy.

Successful treatment of colon cancer is founded on surgical resection of the primary lesion and the regional lymph nodes. The significant number of patients so resected who experience no recurrence, even with positive lymph nodes, indicates that the disease still was confined regionally and that the therapy was effective. Cancer in about 50 per cent of patients does recur, however, and, outside of a small proportion who can be resected again, all patients with recurrence die. There is virtually no curative nonsurgical therapy for colorectal carcinoma.

Colonic Neoplasms↗
PubMed1988

Surgical management of pseudomembranous colitis.

The authors recently studied two cases of pseudomembranous colitis (PMC) that required surgery and combined them with previously reported cases in the literature, which required surgery to propose guidelines for the surgical management of PMC. A total of 21 patients were studied. Indications for surgery included refractory disease in seven patients, toxic megacolon in 12 patients, and perforation in two patients. Operative management ranged from decompressive cecostomy to total proctocolectomy. The best results were obtained with subtotal colectomy and ileostomy. It is concluded that PMC should be managed surgically in a manner analogous to ulcerative colitis. If there is no improvement after 7 days of aggressive medical management, surgical intervention, ileostomy with subtotal colectomy is indicated to prevent complications. Complications of PMC, toxic megacolon and perforation, should also be managed with ileostomy and subtotal colectomy as simple decompression or segmental resection does nothing to alter the underlying disease process.

Colectomy↗
PubMed1987

Analysis of hyperamylasemia in patients with severe head injury.

To evaluate the influence of severe head injury (SHI) on amylase activity, we studied the amylase profile of 60 patients with SHIs and Glasgow Coma Scores less than 10. Fourteen additional multiple trauma patients without head injuries were studied as a control group. We excluded patients with pancreatic injury and abdominal trauma. Total serum amylase (TA), pancreatic isoamylase (PA), and nonpancreatic isoamylase (NPA) levels were measured on Days 0, 2, 4, 7, and 14 postinjury. Values greater than 2 SD above the normal mean were considered elevated. All SHI patients were comatose; 14 died. In the SHI group, TA increased in 23 patients, PA increased in 40, and NPA increased in 14. The source of hyperamylasemia was PA in 14, NPA in one, and mixed in 8 patients. While PA increases occurred throughout the study, NPA elevations occurred early. These increases did not correlate with shock (BP less than 80 mm Hg; 17 patients), facial trauma (24 patients), or associated injury (29 patients). On Day 7 postinjury, the mean TA (215 du%) and the mean PA (203.8 du%) were significantly elevated in the SHI patients compared to controls (122.1 du%, P less than 0.05, Wilcoxon's rank sum test). These data indicate that serum amylase is not a reliable index of pancreatic injury in patients with SHI. Severe head injury and multiple trauma activate pathways that increase amylase levels in the blood, suggesting a central nervous system regulation of serum amylase levels.

Amylases↗
PubMed1987

Gastrojejunostomy: is it helpful for patients with pancreatic cancer?

A retrospective review of palliative outcome of gastrojejunostomy in patients with pancreatic cancer was conducted. Eighty-one patients were analyzed in two groups depending on duodenal patency. Forty-five patients (group I) had no evidence of duodenal obstruction. Thirty-six patients (group II) had evidence of impingement on the duodenum by the pancreatic cancer. A third subset of patients was also studied for outcome. These 21 patients (five group I and 16 group II) had nausea and vomiting as major symptoms and were judged to have the most to gain from gastrojejunostomy. Patients were categorized by outcome. Poor outcome was defined as either death during the hospitalization for gastrojejunostomy or death within 30 days of operation even if the patient left the hospital. Risk for poor outcome depended on group. In group I, 18 of 45 patients (40%) had a poor outcome compared with 25 of 36 (70%) patients in group II (p less than 0.001). Nineteen of the 21 (90%) patients with nausea and vomiting had a poor outcome. It is an unfortunate paradox that the more patients need gastrojejunostomy for pancreatic cancer, the less likely they are to have a favorable outcome. Gastric outlet obstruction in pancreatic cancer appears to be a terminal event. A prospective study is needed to see if any true palliation of vomiting can be affected in these patients.

Adult↗
PubMed1987

Usefulness of selective preoperative chest x-ray films. A prospective study.

Preoperative screening chest x-ray studies continue to be used widely despite the high cost and reported low-yield. Most physicians now use "clinical judgment" to mitigate the frequency of chest x-ray. To determine the usefulness of "selective" preoperative chest x-ray studies, 403 consecutive patients undergoing operation were prospectively studied. Chest x-ray films were analyzed both for abnormality and the frequency with which the changes seen on x-ray films led to cancellation of surgery or resulted in a further evaluation of the pathology discovered. There were 228 male and 175 female patients, (average age: 54 years). A total of 166 (41%) patients had operations performed without a preoperative chest x-ray study. The x-ray studies on 136 of the 237 patients who had preoperative chest x-ray were considered normal. A variety of abnormalities such as effusion, cardiomegaly, atelectasis, or granuloma were found in the remaining 101 patients. Sixty-four of these patients were known from previous studies to have the abnormality that was recorded. Eight of 37 (21%), who had surgery as scheduled, subsequently underwent evaluation for the new pulmonary problem detected on x-ray films. Only two operations were cancelled as a result of the screening x-ray. The majority of abnormalities detected were already known or were considered insufficient for further evaluation. In a metropolitan area of Michigan the cost for a chest x-ray is $70. Projected nationwide, more than $1 billion could be saved on needless "selective" preoperative chest x-ray studies each year. These data suggest that preoperative chest x-ray is still widely overused.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnostic Tests, Routine↗
PubMed1986

Upper gastrointestinal endoscopy for diagnosis of complications of regional hepatic chemotherapy.

Seven of 26 patients undergoing insertion of "Infusaid" perfusion pumps with hepatic artery catheters for regional hepatic perfusion with 5 fluorodeoxyuridine were diagnosed to have gastritis (n = 5) or penetrating duodenal ulcers with catheter exposure (n = 2). Diagnosis is best achieved by esophagogastroduodenoscopy. The ulcers required removal of the pumps and gastric resections. The gastritis responded only to cessation of drug infusion. These complications represent a significant risk to regional hepatic chemotherapy. Physicians caring for this group of patients will be unable to predict which individuals will suffer these complications when using preoperative or postoperative parameters such as age, sex, tumor type, arterial anatomy or flow patterns on nuclear isotope scanning. A high index of suspicion must be maintained during the critical third and fourth cycles of chemotherapy in all patients undergoing regional hepatic chemotherapy.

Adult↗
PubMed1986

Intestinal obstruction in cancer patients. An assessment of risk factors and outcome.

Eighty-four patients with a total of 104 admissions for intestinal obstruction who each also had a history of cancer had their records reviewed to determine what variables, if any, would help predict outcome. Multivariate discriminate analysis was used to assign the patient into one of three outcome possibilities: 1) alive and well, 2) alive with intestinal obstruction, and 3) dead. The computer accurately assigned outcome 71 per cent of the time. Twenty-four per cent of the patients had no cancer found at laparotomy, and had good results. Patients with carcinomatosis did poorly. Females fared much better than males. The natural history of patients with intestinal obstruction and cancer is that about 35 per cent leave the hospital eating normally, 20 per cent are alive but unable to eat, and 45 per cent die on the same hospital admission or shortly thereafter.

Adult↗