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Biomedical subjects

E R Howard

Publications and source records attributed to E R Howard.

At least 91 records · Page 5Linked to original sources
PubMed1989

Late referral for biliary atresia--missed opportunities for effective surgery.

To assess whether clinicopathological features other than the age at operation influence prognosis after surgery for extrahepatic biliary atresia (EHBA) and to determine whether the age at referral has fallen since a previous survey, 50 consecutive cases with EHBA referred between February, 1985, and December, 1987, were reviewed. Liver or spleen size, liver function tests, or histological appearance of liver biopsy specimen before surgery were not predictive of outcome. The jaundice cleared up in 12 of 14 children operated on by age 8 weeks, but in only 13 of 36 operated on later. In 41 referral was delayed. All 25 children in whom surgery was successful are alive and well, while 13 of 25 with unsuccessful surgery have died, at a median age of 1 year. To improve the prognosis of infants with EHBA parents and health staff need a better awareness of the early clinical features of EHBA and of the necessity for prompt referral. Liver disease should be suspected in any infant jaundiced after 14 days of age.

Age Factors↗
PubMed1989

Mesoatrial shunt: a surgical option in the management of the Budd-Chiari syndrome.

The Budd-Chiari syndrome, arising from hepatic venous outflow obstruction, is frequently complicated by inferior vena caval occlusion or obstruction. Satisfactory decompression of the liver by either portacaval or mesocaval shunts may therefore prove impossible or be prone to failure from shunt thrombosis. The mesoatrial shunt which allows the portal vein to drain directly into the right atrium has previously been advocated in this situation. Five patients with the Budd-Chiari syndrome and caval occlusion and/or obstruction have had mesoatrial shunts constructed using externally supported polytetrafluoroethylene grafts. A single thoracoabdominal incision, incorporating a median sternotomy, was found to provide a satisfactory approach. All patients recovered well with resolution of ascites, diminution in liver size and improvement in inferior vena caval pressure gradients. Furthermore, all shunts have remained patent, as determined by Doppler flow studies and contrast-enhanced computed tomographic scanning, during follow-up periods ranging from 9 to 16 months. If these results are supported by longer term studies, the mesoatrial shunt may become the surgical treatment of choice in patients with hepatic vein occlusion and the Budd-Chiari syndrome associated with inferior vena caval obstruction.

Adolescent↗
PubMed1989

Benign non-traumatic inflammatory strictures of the extrahepatic biliary system.

Obstructive jaundice was the presenting feature in 12 patients with benign, non-traumatic strictures of the extrahepatic bile ducts. Ages at presentation ranged from 1.5 to 60 years and 11 were initially referred with diagnoses of malignant strictures. Histological examination, however, showed benign changes of chronic inflammation, with ulceration in seven, which were distinct from those of primary sclerosing cholangitis. All of the patients remain well from 3 to 14 years after surgery. The aetiology of the strictures is not known.

Adolescent↗
PubMed1989

Hepatobiliary tumours of childhood: investigation and management.

The most commonly encountered complications include wound infections, subphrenic collections and bile leaks from the cut liver surface. Stress ulceration of the stomach or duodenum is also not uncommon. Inadvertent bile duct damage has also been reported after major resection in children. The results of surgery for benign lesions are very good and usually depend simply on technical expertise. The results for malignant lesions, however, remain poor. Six series, including our own experience, reported in the last 5 years have shown an overall survival rate of 43% for patients whose tumours were resected for cure. It is difficult to compare results as authors differ in their presentation of results, but details of the series are listed in Table 7. There were no definite prognostic factors to be drawn from these series other than that children with the fibrolamellar variant of hepatocellular carcinoma fared better than those with other hepatomas. It is a sad fact that overall 56% of patients in these series presented with unresectable disease. Mahour et al. described seven patients with unresectable disease who were treated by either chemotherapy alone or in combination with radiotherapy, followed by 'second look' laparotomy and resection. Five of these patients were alive and disease-free for a minimum of 2.5 years after surgery. Thus it is necessary to adopt an aggressive approach to these tumours if one is to see any improvement on the overall figures.

Bile Duct Neoplasms↗
PubMed1989

Biliary atresia.

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Anastomosis, Surgical↗
PubMed1989

Endoscopic sclerotherapy in the management of esophageal varices in 61 children with biliary atresia.

Sixty-one children who have survived 2.5 years or more after corrective surgery for biliary atresia were prospectively followed by endoscopy. Esophageal varices were detected in 41 patients (67%), 17 of whom (28%) had experienced episodes of variceal hemorrhage. Control of variceal bleeding was achieved by endoscopic injection sclerotherapy in all but one child who died from hemorrhage before the completion of treatment. Complications of the technique comprised episodes of bleeding before variceal obliteration (7), esophageal ulceration (5), and stricture (3). These resolved with conservative management and without long-term sequelae. During a mean follow-up period of 2.8 years after variceal obliteration, rebleeding from recurrent esophageal varices developed in only one child and responded to further sclerotherapy. These results are better than those following surgical procedures for portal hypertension in biliary atresia, and therefore endoscopic sclerotherapy is recommended as the treatment of choice.

Biliary Atresia↗
PubMed1989

Variceal haemorrhage in hereditary haemorrhagic telangiectasia.

Hepatic in involvement in hereditary haemorrhagic telangiectasia can lead to cirrhosis and occasionally to portal hypertension and variceal haemorrhage. The ultrasonographic, arteriographic and histological findings are described in a patient with this complication. Hepatic artery embolisation proved unsuccessful in arresting repeated haemorrhage which was eventually controlled by hepatic artery ligation. Porto-systemic venous shunting, an apparently logical approach to management, would probably have aggravated the problem.

Hemorrhage↗
PubMed1989

Biliary atresia.

Biliary atresia remains a serious and devastating surgical condition of early childhood. Despite portoenterostomy almost half of these children remain jaundiced and suffer repeated attacks of bacterial cholangitis or variceal haemorrhage. Recently liver transplantation offers fresh hope for these children.

Biliary Atresia↗
PubMed1988

Assessment of injection sclerotherapy in the management of 152 children with oesophageal varices.

A total of 152 consecutive children with oesophageal varices have been endoscopically reviewed since 1979. In all, 108 of these children presented with variceal bleeding which was managed by injection sclerotherapy. Variceal obliteration was achieved in 33 (92 per cent) children with extrahepatic portal hypertension and 54 (75 per cent) with intrahepatic portal hypertension. Prophylactic injection sclerotherapy was used to obliterate large varices in 11 children with no history of haemorrhage. Bleeding episodes occurred in 38 (39 per cent) children before variceal obliteration was complete. However, the mortality rate from variceal bleeding was only 1 per cent. Complications were oesophageal ulceration (29 per cent) and stricture (16 per cent) which both resolved with conservative management. During a mean follow-up period of 2.9 years after sclerotherapy, recurrent oesophageal or gastric varices developed in 12 (12 per cent) cases, with rebleeding in 9 (9 per cent), but all responded successfully to a second course of treatment. These results are superior to contemporary surgical management and injection sclerotherapy should therefore currently be the primary treatment of choice for bleeding oesophageal varices in children.

Adolescent↗
PubMed1988

Choledochal cyst: a 14-year surgical experience with 36 patients.

The presentation and management of 36 patients with cystic dilatation of the biliary tree seen over a 14-year period is reviewed. There were 28 females and 8 males, a ratio of 3.5:1. The classic triad of jaundice, pain and an abdominal mass was seen in only seven cases. Twelve patients suffered recurrent pancreatitis. There were three cases of variceal haemorrhage from portal hypertension secondary to biliary cirrhosis, and one case of biliary peritonitis from a ruptured cyst. Internal drainage (cystenterostomy) was performed in nine patients but five of these eventually needed cyst excision. Cysts have been excised primarily in the last 21 consecutive patients without mortality. Preliminary external drainage with T tubes was used before cyst resection in three patients who presented with complications of choledochal cysts. Cyst excision and hepaticojejunostomy is now the definitive treatment of choice.

Adolescent↗
PubMed1987

Gastric volvulus in childhood.

Gastric volvulus is a rare surgical emergency in infancy and childhood. Only 51 cases have been reported. We describe four new cases. The classical features of the condition are discussed.

Barium Sulfate↗
PubMed1986

Abdominal tuberculosis: still a problem today.

Thirty cases of abdominal tuberculosis were diagnosed over an 18-year period, 26 being in immigrants; the mean age at presentation was 33 years. There were 25 cases of tuberculous peritonitis, two of tuberculous mesenteric lymphadenitis, and one each of gastric tuberculosis, colonic tuberculosis and tuberculous ischiorectal abscess. The presenting symptoms were of vague ill-health and not diagnostic, and the most common findings were of pyrexia, abdominal tenderness and ascites. The most common haematological abnormalities were raised ESR (22 patients) and mild anaemia (15 patients). Most commonly, diagnosis was made by formal laparotomy (19 cases) with biopsy (18 cases); histological examination gave a positive diagnosis in all 18 cases, but bacteriological examination yielded the tubercle bacillus in only 10 (56%). There were 2 deaths in the series, not directly related to the abdominal tuberculosis. In view of its infrequent and vague presentation, care is required to avoid overlooking the diagnosis of abdominal tuberculosis, particularly in the immigrant population.

Adolescent↗