Biomedical subjects

D M Ilstrup

Publications and source records attributed to D M Ilstrup.

At least 19 recordsLinked to original sources

PubMed1992

Prevention of infection in critically ill patients by selective decontamination of the digestive tract.

OBJECTIVE: To determine whether selective decontamination of the digestive tract using oral and nonabsorbable antimicrobial agents and parenteral cefotaxime prevents infection in critically ill patients. DESIGN: Randomized, controlled trial without blinding. SETTING: Surgical trauma and medical intensive care units in a tertiary referral hospital. PATIENTS: One hundred fifty patients admitted to surgical trauma and medical intensive care units during a 3-year interval, whose condition suggested a prolonged stay (greater than 3 days). INTERVENTION: Patients were randomly allocated to an experimental group (n = 75) that received cefotaxime, 1 g intravenously every 8 hours for the first 3 days only, and oral, nonabsorbable antibiotics (gentamicin, polymyxin, and nystatin by oral paste and oral liquid) for the entire stay in the intensive care unit. Control patients (n = 75) received usual care. MEASUREMENTS: The number of infections, total hospital days, and deaths, as well as the number of days in intensive care unit, were recorded. RESULTS: Control patients experienced more infections (36 compared with 12, P = 0.04), including bacteremias (14 compared with 4, P = 0.05) and pulmonary infections (14 compared with 4, P = 0.03). Although total hospital days, days in intensive care, and the overall death rate all were lower in the treatment group, these differences were not statistically significant. Clinically important complications of selective decontamination of the digestive tract were not encountered. CONCLUSIONS: Selective decontamination of the digestive tract decreases subsequent infection rates, especially by gram-negative bacilli, in selected patients during long-term stays in the intensive care unit.

Administration, Oral↗

PubMed1992

Early gastric cancer.

Early gastric cancer comprises more than 30 per cent of gastric carcinomas treated in Japan but remains an uncommon entity in the western hemisphere. A retrospective review of 48 patients with early gastric cancer undergoing operative treatment between 1965 and 1984 was carried out. The mean patient age was 70 years, in 31 men and 17 women. Preoperative diagnosis was made in 88 per cent of patients undergoing oesophagogastroduodenoscopy with biopsy but upper gastrointestinal radiography was diagnostic in only 20 per cent. Surgical management consisted of subtotal gastrectomy (86 per cent), total gastrectomy (10 per cent) and wide local excision (4 per cent). The operative mortality and morbidity rates were 0 and 38 per cent, respectively. Mean follow-up was 7.7 years, with 44 per cent of patients still alive. Multivariate analysis disclosed only a healthy Eastern Cooperative Oncology Group score (P = 0.002) and a diploid DNA tumour pattern (P = 0.05) as significant prognostic variables of survival. The overall survival rate of patients with early gastric cancer (70 per cent at 5 years) was equivalent to that of an age- and sex-matched control population.

Aged↗

PubMed1992

Lack of association between cytomegalovirus infection, HLA matching and the vanishing bile duct syndrome after liver transplantation.

In this study we evaluated the association between cytomegalovirus infection alone or in relation to human leukocyte antigen matching and the development of vanishing bile duct syndrome, a form of chronic hepatic allograft rejection. A total of 81 consecutive liver transplant recipients were studied. Cytomegalovirus infection developed in 46 recipients (57%), and vanishing bile duct syndrome occurred in 9 recipients (11%). Cytomegalovirus infection developed in only five of the nine patients with vanishing bile duct syndrome. Univariate analysis of pretransplant recipient/donor cytomegalovirus serological tests and human leukocyte antigen typing showed they were not significant risk factors for the development of vanishing bile duct syndrome. Time-dependent analysis of cytomegalovirus infection after transplantation as a risk factor for vanishing bile duct syndrome, in a multivariate analysis with human leukocyte antigen match, showed no statistical significance. In our study, no association was found between cytomegalovirus infection alone or in relation to class I or II human leukocyte antigen match and the subsequent development of vanishing bile duct syndrome.

Acyclovir↗

PubMed1992

Familial adenomatous polyposis: results following ileal pouch-anal anastomosis and ileorectostomy.

To compare the clinical and functional results of ileorectostomy (IR) and ileal pouch-anal anastomosis (IPAA) in patients with familial adenomatous polyposis (FAP), we reviewed the results of 94 IPAA patients and 21 IR patients who were operated upon between 1978 and 1988. The groups were similar with respect to age and sex. None of the patients died postoperatively. Postoperative complications occurred in 28 percent of the IPAA group and in 17 percent of the IR group (P greater than 0.1). Seven percent of IPAA patients described symptoms compatible with pouchitis. Sixty-one percent of IR patients required subsequent fulguration of rectal polyps at least once. IR patients had a mean (+/- SD) of 4 (+/- 2) stools per day, while IPAA patients had 5 (+/- 2) stools per day (P greater than 0.05). No significant difference in daytime soiling was present between IR (6 percent) and IPAA (4 percent). Nighttime spotting was also similar between the two groups. Nighttime soiling, however, was reported by 4 percent of IPAA patients but not by IR patients (P less than 0.05). One IPAA patient (1 percent) required pouch excision for a desmoid tumor, while two IR patients (11 percent) required proctectomy and ileostomy for recurrent dysplastic polyps (P less than 0.05). Adhesions and a shortened ileal mesentery prevented the construction of an ileoanal procedure in these latter patients. In conclusion, the postoperative complication rate and functional results are similar after IR and IPAA in patients with FAP; however, IR does not eradicate rectal polyps and may indeed preclude IPAA for those requiring subsequent proctectomy.

Adenomatous Polyposis Coli↗

PubMed1992

Recurrence of symptoms after percutaneous aortic balloon valvuloplasty: relationship to Doppler diastolic filling values.

Short-term follow-up after percutaneous aortic balloon valvuloplasty shows a high incidence of restenosis. Yet a high percentage of patients with restenosis continue to show symptomatic improvement. Those with decreased left ventricular function originally tend to have a recurrence of symptoms. In this study Doppler-derived diastolic filling values at follow-up were most highly associated with symptom status, suggesting that change in diastolic filling after percutaneous aortic balloon valvuloplasty is one of the factors related to symptoms.

Aged↗

PubMed1992

Colorectal lung metastases: results of surgical excision.

Between 1960 and 1988, 139 consecutive patients underwent pulmonary resection for metastatic colorectal carcinoma. Median interval between colon resection and lung resection was 34 months. Ninety-eight patients (70.5%) had a solitary metastasis. Wedge excision was performed in 68 patients, lobectomy in 53, lobectomy plus wedge excision in 9, bilobectomy in 4, and pneumonectomy in 5. Operative mortality was 1.4%. Localized extrapulmonary colorectal cancer was also resected in 20 patients. Median follow-up was 7 years (range 1 to 20.4 years). Overall 5- and 20-year survival was 30.5% and 16.2%, respectively. Five-year survival for patients with solitary metastasis was 36.9%, as compared with 19.3% for those with two metastases (p less than 0.05) and 7.7% for those with more than two (p less than 0.01). Patients with normal carcino-embryonic antigen had a 5-year survival of 46.8% versus 16.0% for patients with increased levels (p less than 0.01). Five-year survival for patients with resected extrapulmonary disease was 30.0% versus 30.7% for those without extrapulmonary cancer (p = not significant). Repeat thoracotomy for recurrent metastases was done in 19 patients. Five-year survival after the second lung resection was 30.2%. We conclude that resection of colorectal lung metastases is safe and effective, that resectable extrapulmonary disease does not necessarily contraindicate pulmonary resection, and that repeat thoracotomy is warranted in selected patients with recurrent colorectal lung metastases.

Adult↗

PubMed1992

Laparoscopic cholecystectomy: early Mayo Clinic experience.

Prospective data and follow-up information were collected on the initial 200 patients who underwent laparoscopic cholecystectomy at the Mayo Clinic. The operation was completed laparoscopically in all but five patients, who required conversion to laparotomy because of dense scarring or stones in the common bile duct. The median surgical time was 85 minutes. The major postoperative complications were retained stones in the common bile duct (in seven patients), intraperitoneal hemorrhage that necessitated transfusion (in two patients), and intra-abdominal abscess and pulmonary infection (in one patient each). The median hospital stay was 1 day (range, 0 to 8 days), and the median times to full activity and normal employment were 8 days and 12 days, respectively. Laparoscopic cholecystectomy is associated with a low frequency of complications in most patients with symptomatic gallstones and allows a rapid return to normal activity. Currently, laparoscopic cholecystectomy is the treatment of choice for most patients with symptomatic cholelithiasis.

Academic Medical Centers↗

PubMed1992

Venous thromboembolism associated with hip and knee arthroplasty: current prophylactic practices and outcomes.

Joint registry and hospital data bases for 5,024 total hip and total knee arthroplasties done between 1986 and 1988 at the Mayo Clinic were used to study prophylactic measures and frequency of symptomatic deep venous thrombosis and pulmonary embolism. In virtually all patients, graduated compression stockings were used, with or without another type of prophylaxis. Only 44 of 3,115 patients who underwent hip arthroplasty (1.4%) and 32 of 1,909 patients who underwent knee arthroplasty (1.7%) had definite or probable deep venous thrombosis or pulmonary embolism. Death definitely or possibly attributable to pulmonary embolism occurred in 11 patients who underwent hip arthroplasty (0.35%) and 1 patient who underwent knee arthroplasty (0.05%). Although patients with a history of deep venous thrombosis or pulmonary embolism were more likely to receive warfarin than were patients without such a history, the relative risk of symptomatic deep venous thrombosis or pulmonary embolism in patients who underwent hip arthroplasty and received warfarin postoperatively was approximately half that in patients who received other types of prophylaxis. The risk of death from pulmonary embolism was similarly diminished in the group that received warfarin. The lower rates of these complications in the patients who received warfarin support the prophylactic use of this agent after total hip arthroplasty.

Aspirin↗

PubMed1992

Cemented versus noncemented total hip arthroplasty--embolism, hemodynamics, and intrapulmonary shunting.

Bone cement implantation syndrome is characterized by hypotension, hypoxemia, cardiac arrhythmias, cardiac arrest, or any combination of these complications. It may result from venous embolization that occurs in conjunction with intramedullary hypertension in the femur during insertion of the prosthesis in patients undergoing cemented total hip arthroplasty (THA). Intramedullary hypertension does not occur in patients undergoing noncemented THA. In this study, we sought to compare embolization between patients undergoing cemented and noncemented THA and to determine whether this state resulted in cardiorespiratory deterioration. In this prospective investigation of 35 patients undergoing elective THA, we used transesophageal echocardiography and invasive hemodynamic monitoring, and in 12 of them, we monitored distribution of pulmonary ventilation and perfusion intraoperatively. Embolization was significantly greater after insertion of the prosthesis in patients undergoing cemented than in those undergoing noncemented THA. Cemented THA was also associated with decreased cardiac output and increased pulmonary artery pressure and pulmonary vascular resistance. Increases in ventilation-perfusion mismatching, however, could not be demonstrated 30 minutes after insertion of the femoral prosthesis. Intraoperative monitoring for embolism may help physicians assess patients in whom cardiorespiratory function deteriorates during THA.

Aged↗

PubMed1992

Ciprofloxacin versus trimethoprim-sulfamethoxazole: treatment of community-acquired urinary tract infections in a prospective, controlled, double-blind comparison.

In this study, we determined the safety and efficacy of the treatment of adults with urinary tract infection with ciprofloxacin hydrochloride (250 mg twice daily for 10 days) in comparison with trimethoprim-sulfamethoxazole (160 mg of trimethoprim and 800 mg of sulfamethoxazole twice daily for 10 days). Patients with signs and symptoms of urinary tract infection were randomized to receive ciprofloxacin (98 women and 5 men) or trimethoprim-sulfamethoxazole (92 women and 8 men). The success rate of therapy was 91% for both treatment arms of the study. Among seven failures after ciprofloxacin therapy, three were due to relapse of infection and two to side effects that necessitated a change in medication; in addition, two patients had persistent symptoms and required hospitalization. Among the six failures associated with trimethoprim-sulfamethoxazole therapy, four were due to relapse, one to persistence of infection, and one to a side effect that necessitated a change in medication. Among the patients treated with trimethoprim-sulfamethoxazole, 32% had mild or moderate adverse reactions; in comparison, 17% of the ciprofloxacin-treated patients had adverse reactions (P = 0.026). For the treatment of urinary tract infection in adult patients in this study, ciprofloxacin and trimethoprim-sulfamethoxazole were equally effective, but ciprofloxacin was associated with fewer adverse reactions.

Adult↗

PubMed1992

A randomized prospective trial comparing a defined formula diet, corticosteroids, and a defined formula diet plus corticosteroids in active Crohn's disease.

Although defined formula diets may be useful for initial episodes of Crohn's disease, the effects of these diets on subsequent attacks of Crohn's disease or in conjunction with corticosteroids are unknown. To evaluate these issues, we studied 27 patients in a randomized prospective trial. Ten patients received only prednisone (group I), nine received only a defined formula diet (Vital HN [high nitrogen]) (group II), and eight received a combination of prednisone and Vital HN (group III). At the time of entry into the study, the groups were similar with respect to age, sex, Crohn's Disease Activity Index, previous and current treatments, anatomic site of disease, and nutritional status. After 1 month of treatment, we noted seven successes (70%) and three failures in group I (prednisone only), three successes (33%) and six failures in group II (Vital HN only), and six successes (75%) and two failures in group III (combination therapy). Four patients randomized to receive only Vital HN were unable or unwilling to tolerate the defined formula diet. Of the five patients who were able to take the defined formula diet for 1 month, however, three (60%) were successfully treated. The patients who received prednisone (groups I and III) responded better than did the patients who received only the defined formula diet. These results may be attributable to the use of a nonelemental diet or the treatment of patients who were not experiencing an initial attack of Crohn's disease or who had previously received corticosteroids. The expensive and often poorly tolerated defined formula diets should not be considered as a substitute for standard therapy with corticosteroids in Crohn's disease.

Adult↗

PubMed1992

The Zollinger-Ellison syndrome. A collective surgical experience.

A retrospective study of 90 surgically treated patients with the Zollinger-Ellison syndrome seen from 1958 through 1990 was performed. Fifteen patients had Zollinger-Ellison syndrome as a manifestation of multiple endocrine neoplasia type I. Preoperative tumor localization was positive in 46% of 54 patients studied. Gastrinomas were identified in 66% of patients, 38% of the tumors being malignant. Postoperative eugastrinemia was achieved in 11% of patients after a variety of surgical procedures. Exploratory laparotomy provides the only chance for cure and identifies the significant prognostic factors associated with long-term patient survival: small tumor size, extrapancreatic primary, and absence of tumor metastases.

Adolescent↗

PubMed1992

Perioperative blood transfusion and determinants of survival after liver resection for metastatic colorectal carcinoma.

The authors reviewed their institutional experience with liver resection for metastatic colorectal carcinoma to (1) determine whether perioperative blood transfusion affects survival; (2) identify prognostic determinants; and (3) estimate the patient requirement for a prospective randomized trial designed to demonstrate efficacy of liver resection. Two hundred eighty consecutive patients treated by potentially curative liver resection between 1960 and 1987 were included. Data were obtained for all but 10 patients for at least 5 years after operation or through 1990. Actuarial survival curves related to potential prognostic determinants were analyzed with the log-rank test. Overall, survival was 47 +/- 3% at 3 years and 25 +/- 3% at 5 years, including 4% 60-day operative mortality rate. Eighty-one patients who did not receive blood 7 days before to 14 days after operation had 60 +/- 6% 3-year and 32 +/- 6% 5-year survival compared with 40 +/- 4% and 21 +/- 3% survival rates for 183 patients who received at least one unit (p = 0.03, operative deaths excluded). Extrahepatic disease (p = 0.015), extrahepatic lymph node involvement (p = 0.002), satellite configuration of multiple metastases (p = 0.0052), and initial detection by abnormal liver enzymes (p = 0.0005) were associated with poor survival rates. Synchronous presentation of metastatic and stage B primary disease was associated with a favorable prognosis (p = 0.003). The requirement for a prospective randomized trial estimated by an exponential survival model would be 36, 74, 168, or 428 patients if 5-year survival without resection were 1, 5, 10, or 15%. We conclude that (1) perioperative blood transfusion may be adversely associated with survival; (2) extrahepatic disease, extrahepatic lymph node involvement, satellite configuration, and initial detection by clinical examination or a liver enzyme abnormality portend a poor prognosis; and (3) a prospective randomized trial of liver resection is impractical because of the large patient requirement, at least by a single institution.

Aged↗

PubMed1992

Association of coagulation tests with blood use during liver transplantation.

This study is a retrospective review of 263 adult patients who underwent either their first or their second orthotopic liver transplantation between March 1985 and January 1992. Activated partial thromboplastin time (APTT) and prothrombin time (PT) were analyzed for correlation with the amount of blood transfused 70 minutes after reperfusion. The data were analyzed to estimate correlation between variables using Spearman's rank correlation coefficient. A P value less than .05 was considered significant. Data analysis demonstrated a positive association between APTT and blood transfusion in all disease states, with the exception of patients who had retransplantation. A positive association existed between PT and the amount of blood transfused in patients with alcoholic liver disease, primary biliary cirrhosis, and primary sclerosing cholangitis.

Adolescent↗

PubMed1992

Relationship of nuclear DNA content to clinical and pathologic findings in patients with primary hepatic malignancy.

BACKGROUND: Nuclear DNA content of a variety of tumors has proven valuable as a prognostic indicator. The purpose of this study was to analyze patterns of DNA content in primary hepatocellular carcinoma and to correlate ploidy status with patient survival. METHODS: The relationship of nuclear DNA content to host and tumor characteristics was analyzed in 46 patients with primary hepatic malignancy who had undergone resection with curative intent between 1975 and 1985. RESULTS: Flow cytometric measurement of tumor DNA content revealed a diploid pattern in 33%, tetraploid or polyploid in 30%, and aneuploid in 37% of cases. There was no significant correlation between tumor DNA content and demographic or pathologic findings in the patients studied. Moreover, there was no difference in survival between patients with diploid versus nondiploid tumors. CONCLUSIONS: These findings suggest that tumor DNA content has no prognostic value in patients with primary hepatic malignancy.

Carcinoma, Hepatocellular↗

PubMed1992

Ruptured abdominal aortic aneurysms: repair should not be denied.

The records of 231 patients (189 men, 42 women) treated during the last decade for ruptured infrarenal abdominal aortic aneurysm were reviewed to evaluate complications and mortality rates and to determine if preoperative factors would preclude attempt at surgical repair. Mean age was 73.7 years (range, 50 to 95 years). Fifty-seven patients (24.7%) were greater than or equal to 80 years of age. Sixty-eight patients (29.4%) had known abdominal aortic aneurysm before rupture. Preoperative systolic blood pressure was less than or equal to 90 mm Hg in 155 patients (67.1%). Fifty-six patients (24.2%) had cardiac arrest before operation. The overall mortality rate from admission until the end of the hospital stay was 49.4% (114 of 231). Seventeen patients (7.4%) died in the emergency department, 40 (17.3%) in the operating room, 27 (11.7%) during the first 48 postoperative hours, and 30 (13.0%) died later but during the same hospitalization. The 30-day operative mortality rate was 41.6%. Mean age of those who died was higher (75.3 years) than of those who survived (72.2 years) (p less than 0.02). Of patients greater than or equal to 80 years, 43.9% survived. Survival was lower among women (35.7%) than men (54.0%; p less than 0.04). A high APACHE II score, a low initial hematocrit, preoperative hypotension, and chronic obstructive pulmonary disease were associated multivariately with increased mortality rates (p less than 0.02). However, 59 of the 155 patients (38.1%) with preoperative hypotension survived. Deaths were high (80.4%) among patients with cardiac arrest (45 of 56); still, 28.2% of patients (11 of 39) survived repair after cardiac arrest.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗

PubMed1991

Total gastrectomy for advanced cancer. A worthwhile palliative procedure.

Subtotal gastric resection usually provides the best palliation in advanced gastric cancer; however, if total gastrectomy (TG) is required there is doubt about its benefit. The authors reviewed 53 consecutive patients undergoing TG for advanced gastric adenocarcinoma between 1980 and 1989. Indications for TG were tumor location in 30% and extent of tumor in 70%, including nine patients (17%) with linitis plastica. Four patients (8%) died postoperatively, and six patients required reoperation for postoperative complications. The median postoperative hospital stay was 13 days. The median survival was 19 months, and 13 patients (24%) lived for more than 2 years. The quality of life was graded in survivors as good in 59%, satisfactory in 28%, and poor in 13% of patients. It was concluded that TG is a worthwhile procedure for selected patients, even in the presence of advanced disease, providing prolongation of good quality of life with low morbidity and mortality.

Adenocarcinoma↗

PubMed1991

Radical resection for carcinoma of the ampulla of Vater.

One hundred four consecutive patients who underwent radical resection for ampullary cancer between 1965 and 1989 were retrospectively reviewed. Frequent clinical findings included jaundice (67%), significant (greater than 10%) weight loss (42%), and anemia (27%). Eighty-seven patients (84%) underwent a subtotal pancreatectomy, and 17 patients (16%) underwent a total pancreatectomy. The postoperative mortality was 5.7% (six patients), and reoperation for postoperative complications was required in six patients. The 5- and 10-year survival rates were 34% and 25%, respectively. Eight patients died of tumor recurrence more than 5 years after resection. Patient survival was significantly impaired by microscopic lymphatic invasion, regional nodal metastasis, tumor grade, and the epithelium of origin. In a multivariate analysis, only microscopic lymphatic invasion significantly reduced patient survival. Radical resection for ampullary cancer can be performed with a low morbidity and mortality and should remain the procedure of choice for ampullary carcinoma.

Adenocarcinoma↗