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G D Branum

Publications and source records attributed to G D Branum.

At least 37 records · Page 2Linked to original sources
PubMed1996

Evaluation and management of postfundoplication dysphagia.

OBJECTIVES: Persistent dysphagia occurs in 3-24% of patients after fundoplication. There are virtually no data on the success or safety of endoscopic dilation to relieve postfundoplication dysphagia. The aim of this study was to review our experience with endoscopic management of patients with dysphagia after fundoplication. MATERIALS AND METHODS: Thirty-five patients (mean age 49 yr; 12 males, 23 females) with dysphagia after fundoplication were referred for endoscopic dilation. Twenty-nine patients had undergone one fundoplication (group A), and six patients had undergone two or more operations (group B). The integrity of the fundoplication was evaluated by barium esophagram and upper endoscopy. Median follow-up after the initial postoperative dilation was 13 months. RESULTS: The 29 patients in group A were dilated to a mean (+/- SD) of 52 +/- 4F during a mean (+/- SD) 1.9 +/- 1.1 dilation sessions per patient. No complications, such as disruption of the fundoplication, resulted from endoscopic dilation, and no one developed new reflux symptoms. Dysphagia resolved in 15 (52%) patients after dilation. The most important prognostic feature was endoscopic or radiological evidence of a slipped fundoplication. Dilation was successful in relieving dysphagia in only three of 11 (27%) patients with a slipped fundoplication, compared with 12 of 18 (67%) patients with an intact fundoplication (p = 0.05). Dysphagia resolved in only one of the six patients in group B. CONCLUSIONS: Endoscopic dilation is safe and often effective in patients with postfundoplication dysphagia. However, patients with a slipped fundoplication or who have undergone multiple fundoplications respond poorly to endoscopic dilation.

Barium Sulfate↗
PubMed1995

The use of pancreatic ductoscopy in the operative management of benign and malignant pancreatic disorders.

Direct visualization of the pancreatic duct was helpful in decision making during complex pancreaticobiliary operations. Two-, 3-, or 5-mm scopes were introduced into the pancreatic ducts of 32 patients with pancreatic disorders. Scopes were passed into the ductal system of: (1) 16 patients undergoing pancreaticojejunostomy; (2) six patients undergoing pancreaticoduodenectomy; (3) four patients with pancreatic pseudocysts or choledochal cysts: (4) two patients undergoing resection of the pancreatic tail; and (5) two patients undergoing accessory ductoplasty for pancreas divism or stricture. Eight patients had calculi removed utilizing the scope, and multiple strictures were identified and filleted. Pancreatic ductoscopy was used in two patients to document successful sphincteroplasty of an accessory duct. In two instances benign pancreatic duct tumors were removed. Pancreatic ductoscopy was used to search for coexistent duct neoplasms in the eight patients who underwent resection. The technique permits intraoperative inspection, biopsy, and removal of lesions intrinsic to the ductal system. Combined with surgical procedures this endoscopic method proved a useful adjunct in difficult cases.

Adult↗
PubMed1993

Clinical features and mechanisms of major laparoscopic biliary injury.

Laparoscopic cholecystectomy has quickly become the gold standard for the treatment of symptomatic cholelithiasis. With the introduction of this new technique has come a learning curve, with a higher than expected initial rate of complications. The most significant complication, as with open cholecystectomy, is injury to the bile duct. This article reviews the clinical features and mechanisms of major biliary injury in laparoscopic cholecystectomy.

Bile Ducts↗
PubMed1992

Bile acid transport in the anhepatic rat.

Hepatocyte dysfunction eventually results in the loss of canalicular bile formation. Without canalicular flow, intestinal bile acid may originate from plasma by reverse transport. Anhepatic rats with preserved intestinal function permit evaluation of such transport. In the present study, plasma taurocholate clearance was markedly decreased in anhepatic rats. The relative proportion of free cholate increased with time. Peripheral tissues contained virtually only cleared taurocholate, but the intestinal contents were mainly free cholate. This indicates the intestinal contents as the source of the plasma cholate and shows an equilibrium between intestinal and plasma bile acid even without bile flow. The enteral administration of an anion exchange resin to anhepatic rats increased intestinal bile acid recovery and decreased the bile acid recovery in tissue. Plasma bile acid concentration was decreased and fractional loss increased threefold, confirming the anhepatic plasma-intestine bile acid equilibrium. However, the enhanced plasma clearance produced by the resin was less than 1% of the fractional loss found in the intact rat. These data show a very limited bile acid flux between intestine and plasma without bile flow, which could be modestly influenced by an intestinal bile acid sequestrant.

Animals↗
PubMed1992

The technique of laparoscopic cholecystectomy in children.

Twelve children underwent elective laparoscopic cholecystectomy for symptomatic cholelithiasis during a 10-month period in one institution. The operative technique that has been described for adults was modified because of the smaller dimensions of pediatric patients. These modifications are discussed in this report, as are new alternatives for evaluating the common duct. No operative complications or conversions to open cholecystectomy occurred, and no complications after surgery were seen during an average follow-up period of 4.5 months. The benefits of laparoscopic cholecystectomy include decreased pain and ileus after surgery, shortened hospitalization, and improved cosmesis. Laparoscopic cholecystectomy is safe and efficacious in children, and it compares favorably with traditional cholecystectomy in the pediatric age group.

Adolescent↗
PubMed1992

The effects of liver denervation on the regulation of hepatic biliary secretion.

Effects of liver denervation on bile formation were studied in eight dogs prepared with chronic biliary fistulas. The animals were studied in the basal state, after feeding, and during infusion of glucagon 50 ng/kg/min, secretin 2 U/kg/hr, or somatostatin 200 ng/kg/min. After this first set of experiments the animals underwent a total hepatic denervation that consisted of section of the hepatic ligaments and a careful dissection of the portal vein, hepatic artery, and common duct with stripping of all the surrounding connective tissue and topical application of phenol. The above experiments were then repeated. Denervation did not modify bile flow, or bile salts, cholesterol, or phospholipid concentration or output. Biliary response to glucagon and secretin was similar before and after denervation. Somatostatin had an anticholerectic effect in both intact and denervated animals, but significantly reduced bile salt output only in the intact dogs. Feeding had a choleretic effect pre- and postdenervation, and the infusion of somatostatin following feeding decreased bile flow to the same degree before and after denervation. In the intact animals the output of all three biliary lipids was reduced by somatostatin after feeding but they were unaffected by somatostatin after denervation. Moreover, cholesterol and phospholipid outputs were stable after feeding in intact animals, but significantly decreased after denervation. 14C-erythritol clearance studies indicated no change in the canalicular component of bile flow with denervation, except again during somatostatin suppression of feeding. These data indicate that basal bile flow is normal after denervation but that innervation may play an important role in the modulation of responses to somatostatin and more complex stimuli such as feeding.

Animals↗
PubMed1991

Indications for and the technique of local resection of tumors of the papilla of Vater.

Local resection of tumors of the papilla of Vater was performed in six cases (three benign adenomas and three adenocarcinomas). Pathology was suggested in all cases by endoscopic biopsy and confirmed by operative excision. A method of excision of the tumor and reconstruction of the pancreaticobiliary apparatus was used that eliminated all gross and microscopic disease. Only one of the patients with benign disease (familial polyposis) suffered from local recurrence. All three patients with malignant tumors developed local recurrences within 2 years of resection. Local resection seems to be a viable alternative to Whipple's resection in patients with benign tumors. In malignant cases, local resection should be considered only a palliative procedure and confined to elderly patients with severe concomitant disease and patients in whom a more radical procedure would incur an undue surgical risk.

Adenocarcinoma↗
PubMed1991

Role of surgical intervention in the management of intestinal metastases from malignant melanoma.

Malignant melanoma is the most common metastatic lesion of the intestine. Surgical consultation is often sought when bowel metastases become symptomatic. To determine the role of surgical intervention in such cases, a database of 6,000 melanoma patients was examined, and a subset of 102 patients with small intestinal or colonic metastases were identified premortem. Common presenting features included abdominal pain with or without acute symptoms (29% of patients), obstruction or intussusception (27%), and bleeding (26%). The presence of metastatic lesions was confirmed by surgical exploration in 80% of patients, endoscopic procedures in 11%, and percutaneous biopsy in 5%. Cure was achieved in 36 patients by resection, which resulted in the removal of all demonstrable disease. The subsequent mean length of survival in this group was 31 +/- 5.2 months. Forty-two patients underwent palliative enteric bypass or debulking procedures, and 24 patients received either chemotherapy alone or symptomatic treatment. The average length of survival in these latter groups was 9.6 +/- 15.9 and 9.6 +/- 3.6 months, respectively, both of which were significantly less than the duration of survival in the complete resection group (p less than 0.05). Small or large bowel resection for bleeding or obstruction and enteric bypass for obstruction provided symptomatic relief in 92% of patients thus treated. There was no operative mortality in the series. An aggressive search for resectable disease in patients with symptoms secondary to intestinal metastases from malignant melanoma should be performed. Surgical intervention may then allow the palliation of pain, obstruction, and bleeding. Survival can be significantly prolonged if it is possible to remove all demonstrable disease.

Adult↗
PubMed1991

Biliary response to glucagon in humans.

Glucagon has been demonstrated to have profound effect on biliary secretion in several species. Glucagon's biliary effects were studied in humans following biliary tract surgery. Nine patients underwent common bile duct exploration and insertion of a balloon-occludable t tube. An aliquot of the collected sample was kept and the enterohepatic circulation was maintained by reinfusion of the collected bile via the distal t-tube port. Glucagon increased bile flow and decreased cholesterol and phospholipid output during stable bile acid output. Furthermore high-performance liquid chromatographic analysis of bile acid profiles revealed no significant changes in bile salt species or conjugation after glucagon infusion. Glucagon is probably important in the physiologic regulation of biliary secretion in humans.

Bile↗
PubMed1991

The role of resection in the management of melanoma metastatic to the adrenal gland.

Melanoma metastatic to the adrenal gland diagnosed before death was exceedingly rare before the development of computed tomographic (CT) scanning. The records of 28 patients with melanoma metastatic to the adrenal gland seen since 1975 were reviewed. Eighteen patients were men and 10 were women. Twenty-three patients had unilateral disease. Four patients were diagnosed only at autopsy, leaving 24 for analysis of treatment and survival. Twenty-one patients had received specific active immunotherapy, four had received chemotherapy (dacarbazine, lomustin, bleomycin, and vincristine), and three had received both before the diagnosis of their adrenal disease. Adrenal metastases were diagnosed by CT scanning in 14 patients with symptoms, 10 (91%) of whom had pain. Ten patients were diagnosed by CT before entry into a chemotherapy protocol. Of eight patients who underwent resection of all known disease, five underwent unilateral adrenalectomy, two underwent unilateral adrenalectomy and bowel resection, and one underwent bilateral adrenalectomy. Two patients underwent partial resection of large unilateral tumors. Fourteen patients with adrenal metastases and disease elsewhere were initiated or continued with chemotherapy or were treated symptomatically. Mean survival in the group that underwent resection for cure was 59 months (3 to 112 months), whereas survival in the group with unresectable tumors was 15 months (1.5 to 132 months). Four of eight patients who underwent resection for cure lived more than 5 years after detection of adrenal metastasis, whereas in only one of 14 patients with unresectable tumors was the same true. Patients with metastatic melanoma localized to one or both adrenal glands may benefit from early detection and surgical intervention.

Adrenal Gland Neoplasms↗
PubMed1990

Subtotal colectomy for familial polyposis. A clinical series and review of the literature.

Familial polyposis is an inherited syndrome in which untreated persons have virtually a 100% incidence of developing colon cancer. Much controversy exists over whether subtotal colectomy with ileoproctostomy is the appropriate procedure in these patients owing to the risk of subsequent cancer in the retained portion of the rectum. At Duke University Medical Center, Durham, NC, a group of 25 patients chose to undergo the subtotal colectomy and ileoproctostomy instead of the definitive total proctocolectomy. Of the 25 patients in this series, invasive adenocarcinoma has developed in the rectal segment in only 1 patient. This patient, the oldest in our series, had carcinoma in situ in her initial operative specimen and has done well following an abdominal perineal resection and 13 years of follow-up. Six other patients have subsequently undergone definitive resections of the rectum because of intractable benign polyps. These results compare favorably with those reported in the literature. We conclude that subtotal colectomy with ileoproctostomy is still a useful and successful mode of treatment for select patients with familial polyposis if they are followed up frequently and aggressively and if the surgeon maintains a low threshold for recommending completion proctectomy.

Adenomatous Polyposis Coli↗
PubMed1990

Clinical significance of ultrasonographically detected coincidental gallstones.

The clinical profiles of 139 patients with gallstones found coincidentally during ultrasonography were reviewed and the patients followed prospectively for five years. Indications for ultrasonography included follow-up of abdominal malignancy (33%), evaluation of abdominal aortic aneurysm or other arteriosclerotic vascular disease (22%), renal insufficiency (12%), and lower abdominal pain (7%). At the time of gallstone detection, 14 patients (10%) had symptoms attributable to cholelithiasis. Over the next five years, only 15 patients (11%) developed episodes resembling biliary pain. Nine patients underwent cholecystectomy during this period. Three of the cholecystectomies were incidental to other abdominal procedures. Two cholecystectomies were performed as emergencies for gallstone complications with no perioperative mortality. Interestingly, 54 patients (40%) with coincidental gallstones died during the follow-up period. All the deaths were unrelated to gallstones. These data indicate that ultrasonographically detected coincidental gallstones rarely have clinical significance, leading strong support to the expectant management of most patients with purely coincidental gallstones.

Age Factors↗
PubMed1990

Biliary response to glucagon and insulin following hepatic transplantation in humans.

Glucagon and insulin are postulated to be physiologic regulators of hepatic biliary secretion. Effects of these hormones were studied following orthotopic transplantation. Five adult hepatic graft recipients had triple lumen t-tubes placed at the time of surgery and were studied 3 months after surgery. Experiments were performed after cholangiographic confirmation of t-tube placement and function. After overnight fast, t-tubes were inflated and bile was collected. A small quantity was saved for analysis and the remainder was reinfused to maintain enterohepatic circulation. After 1 hr of observation, the patients received a 2-hr infusion of insulin (0.125 U kg-1 hr-1), glucagon (2 micrograms kg-1 hr-1), or 0.9% saline. During saline infusions, all parameters remained stable. As has been previously demonstrated in the canine model and intact patients, bile salt outputs were constant under all experimental conditions. Glucagon stimulated bile secretion by 30% (6.7 +/- 1.5 to 8.7 +/- 1.2 ml/15 min) and inhibited biliary cholesterol output by 47% (16.4 +/- 3.2 to 8.7 +/- 1.5 mg/15 min). Bile flow and lipid secretion were not affected by insulin. Glucagon had profound effects on bile flow and lipid secretion, suggesting effects independent of innervation, while insulin at this dose had no statistically significant effects.

Bile↗
PubMed1990

A model for biliary and vascular access in the unanesthetized, unrestrained rat.

Conventional methods for vascular access and bile collection in the rat, such as the isolated perfused liver, study under anesthesia, and animal restraint, do not allow study of a physiologically intact rat. A simple technique for vascular access and monitoring of biliary secretions in the intact, unrestrained, unanesthetized rat for extended periods of time is described. Sample experiments demonstrated a 20% complication rate and an 85% 24-hour survival. This model may prove useful in studies requiring chronic vascular and visceral catheterization in the awake rat.

Anesthesia↗
PubMed1990

Hepatic abscess. Changes in etiology, diagnosis, and management.

Most recent reviews of pyogenic hepatic abscess emphasize percutaneous versus open surgical management and devote little time to studying the etiology or the clinical condition of the patient. In this study a detailed review was performed with a computerized analysis of multiple clinical parameters in 73 patients treated for pyogenic hepatic abscess during a 17-year period. The mean age of the patients was 55 years and 38 of them (52%) were male. The mortality rate was comparable for solitary (17%) and multiple (23%) abscesses. The likelihood of death was higher with antibiotic treatment alone (45%) or percutaneous treatment (25%) than with surgical treatment (9.5%). The primary determinant of outcome, however, was the underlying disease, i.e., malignancy or an immunocompromised patient, rather than solitary versus multiple abscesses. In addition the incidence of hepatic abscess seen at this center has doubled from the first half to the second half of the review, reflecting a population of more severely ill patients. It is apparent that in current clinical practice several methods of management are effective, and the choice of therapy should be determined by individualized selection. The principle of timely diagnosis and prompt institution of treatment appropriate to the specific patient remains the standard of care in this potentially grave disease.

Adolescent↗
PubMed1990

Evaluation of selective liver denervation methods.

This study compares four methods of hepatic denervation and defines the rate and physiological significance of reinnervation. Five groups of rats were prepared: 10 underwent orthotopic liver transplantation. In nine rats a 90% aqueous phenol solution was applied circumferentially to the portal vein. Thirteen rats underwent microsurgical denervation; 28 received different doses of 6-hydroxydopamine (6-HODA) administered as a single intraportal injection [50 (n = 10), 75 (n = 6), and 100 mg/kg (n = 6)]. Twelve rats were studied as controls. Rats were killed 1, 4, and 8 wk after surgery to determine liver tissue content of norepinephrine (NE). Changes in mean arterial pressure (MAP) in response to hepatic nerve stimulation, which was supramaximum in intensity and frequency, were measured before rats were killed. NE content in controls ranged from 121 to 204 ng/g and MAP increased by 30-38 mmHg after electrical stimulation. At 1, 4, and 8 wk after treatment the liver NE content was less than 1, 2.3, and 20.2 ng/g in the transplant group; less than 1, 2.7, 4.1 ng/g in the phenol group; and 17.2, less than 1, and 3 ng/g in the surgically denervated group. In the 6-HODA group, values were 18.9, 47, and 61.5 ng/g (50 mg/kg); 5.7, 20.2, and 15 ng/g (75 mg/kg); and 7.7, 2.5, and 17.5 ng/g (100 mg/kg). When the level of NE was undetectable, MAP increase after stimulation was 0-18% that of controls. When NE content was 15-23% of normal, MAP increased 49-62% regardless of the denervation technique.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1989

Surgical management of pancreatic lymphoma.

The clinical and pathologic records of 12 patients with pancreatic lymphoma were reviewed retrospectively to determine distinguishing clinical features. Radiologically, all patients had large abdominal masses in the region of the pancreas. Preoperative percutaneous cytologic biopsy specimens failed to make the diagnosis, and two specimens were interpreted incorrectly as poorly differentiated adenocarcinoma. The diagnosis was difficult to make in two cases, even at laparotomy. Four patients underwent a biliary bypass, and two underwent a concomitant gastric or duodenal bypass. Two patients died postoperatively. Four patients responded well to chemotherapy and/or radiation therapy, and two did not have any recurrences at 3 and 7 years postoperatively. Although rare, lymphoma should be considered in patients with undiagnosed pancreatic masses. The diagnosis may only be made with appropriate preoperative or intraoperative suspicion, and treatment may be rewarding, particularly in comparison with pancreatic adenocarcinoma.

Adult↗