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Biomedical subjects

G Maddern

Publications and source records attributed to G Maddern.

At least 19 recordsLinked to original sources
PubMed1999

The Glissonian approach of the hilum.

The detailed knowledge of the segmental anatomy of the liver has led to a rapid evolution in resectional surgery based on the intrahepatic distribution of the portal trinity (the hepatic artery, hepatic duct and portal vein). The classical intrafascial or extrahepatic approach is to isolate the appropriate branch of the portal vein, hepatic artery and the hepatic duct, outside the liver substance. Another method, the extrafascial approach, is to dissect the whole sheath of the pedicle directly after division of a substantial amount of the hepatic tissue to reach the pedicle, which is surrounded by a sheath, derived from Glisson's capsule. This Glissonian sheath encloses the portal trinity. In the transfissural or intrahepatic approach, these sheaths can be approached either anteriorly (after division of the main, right or umbilical fissure) or posteriorly from behind the porta hepatis. We describe the technique for approaching the Glissonian sheath and hence the hepatic pedicle structures and their branches by the intrahepatic posterior approach that allows early delineation of the liver segment without the need for ancillary techniques. In addition, the indications for the use of this technique in the technical and oncologic settings are also discussed.

Digestive System Surgical Procedures↗
PubMed1999

Peripheral cholangiocarcinoma: presentation, diagnosis, pathology and management.

AIMS: To report the clinical presentation, diagnosis and results of aggressive surgical management in patients with intrahepatic cholangiocarcinoma. METHODS: From February 1988 to June 1998, 21 patients underwent laparotomy with a 90% resectability rate (19 resections). The 19 liver resections included right trisegmentectomy in six patients, right lobectomy in five, wedge resection in four, left lobectomy in two, left trisegmentectomy in one and a lateral segmentectomy in one. Resection of the biliary confluence with reconstruction by a Roux en Y hepaticojejunostomy was performed in three patients. RESULTS: Mild abdominal pain, weight loss and gastrointestinal disturbances were the most frequent clinical signs. Jaundice was present in only four patients. Pre-operative radiological investigations (abdominal ultrasound, computed tomography, arteriography) correlated with pathological findings in only 60% of cases. Pre-operative histological findings (fine-needle cytology, liver biopsy), available for 19 patients, did not always provide an accurate diagnosis. The mortality and morbidity rates were 5 and 47%, respectively. The median survival of resected patients was 18 months. Overall patient and tumour-free survival rates were 83 and 31% at 1 year, 33 and 16.5% at 2 years and 16.5 and 16.5% at 3 years in the resected group. Lymph-node spread, vascular invasion, positive margins and bilobar distribution were associated with a high recurrence rate and poor prognosis. CONCLUSION: Despite the advanced stage of these tumours at presentation, patient survival can be improved by aggressive surgical resection. As intrahepatic cholangiocarcinoma usually develops in a non-cirrhotic liver, major hepatic resections to obtain disease-free margins can be performed with low mortality.

Adult↗
PubMed1999

Splenic infarction complicating ligation of a gastroduodenal artery aneurysm.

BACKGROUND: Aneurysms of visceral arteries are rare, but may lead to dramatic situations of intraabdominal or retroperitoneal hemorrhage in case of rupture. CASE REPORT: We report the case of a 72-year-old patient who developed a hemorrhagic shock following a total hip replacement due to the rupture of an aneurysm of the gastroduodenal artery. Angiography also demonstrated a high-grade stenosis of the celiac trunk. The ruptured aneurysm was ligated as a live-saving procedure, but due to the stenosis in the celiac trunk the patient developed a splenic infarction followed by partial tissue liquefication. This was treated conservatively and after 3 months, the computed tomography showed an atrophic residual spleen. SUMMARY: Diagnostic and therapeutic approaches to visceral vascular aneurysms are discussed including the potential complications of splenic infarction.

Aged↗
PubMed1998

[Pancreatectomy after neoadjuvant chemoradiotherapy for potentially resectable exocrine adenocarcinoma of the pancreas].

The last of the therapeutic modalities proposed for exocrine adenocarcinoma of the pancreas which appears to be potentially resectable, neoadjuvant chemoradiotherapy has many prerequisites: validation of the diagnosis, determination of resectability with a high degree of confidence and palliation of biliary obstruction when present. This rather complex strategy does not seem to have major deleterious effects on the operative procedure or the postoperative course. Only multicentric protocols will, in the near future, give an answer to the question of secondary toxic effects and improvement of survival of this new therapeutic strategy.

Adenocarcinoma↗
PubMed1995

Venous allografts: a useful alternative to venous autografts in digestive surgery.

Over a 16 month period seven patients underwent surgery using venous allografts either to reconstruct the portal vein, or to construct a mesocaval 'H' graft or a shunt between the coronary vein and the subhepatic inferior vena cava. The allografts were harvested during multiorgan procurement from the bifurcation of the inferior vena cava, the common iliac vein and the external iliac vein and kept in a preservation solution at 4 degrees C for a mean time of 6 days (range 1-29) before use. Subsequent thrombosis was clinically evident in only two patients. The use of venous allografts appears to be a useful alternative to other venous replacements.

Adolescent↗
PubMed1994

A randomized study of chemotherapy, radiation therapy, and surgery versus surgery for localized squamous cell carcinoma of the esophagus.

BACKGROUND: Despite well-established surgical approaches, the prognosis for patients with squamous cell carcinoma of the esophagus remains dismal. To assess the benefit of adjuvant chemotherapy and radiation therapy (CRT), a randomized trial with and without sequential preoperative CRT was undertaken; CRT combined 20 Gy and two courses of 5-FU and cisplatin. METHODS: Patients were included on the basis of the following criteria: squamous cell carcinoma of the esophagus, younger than 70 years of age, World Health Organization status below 2, estimated survival time greater than 3 months, and no previous treatment for the cancer. Patients were not included if they had experienced a loss in body weight greater than 15% or had tracheoesophageal fistula, metastases, or uncontrollable infection. RESULTS: Eighty-six patients thus fulfilled the criteria for inclusion (41 CRT, 45 non-CRT). The groups were well-matched for age, sex, tumor location, size, and grade. Operative mortality was 8.5% and 7%, respectively, for each group with a 27-day hospital stay for both groups. Long-term survival was not significantly different, with 47% of both groups alive at 1 year. CONCLUSIONS: The authors concluded that this neoadjuvant treatment did not change operative mortality or survival time for patients with squamous cell carcinoma of the esophagus.

Adult↗
PubMed1994

Surgical management of portal hypertension.

The surgical management of portal hypertension depends on the location of the obstruction. Suprahepatic obstruction is usually optimally treated by a surgical portacaval shunt. In extrahepatic obstruction the treatment should be sclerotherapy. For intrahepatic obstruction in emergency situations, sclerotherapy is the first choice, with portacaval systemic shunts or transjugular intrahepatic portal systemic stent shunt the second option. Liver transplantation in other situations should, if possible, be considered ahead of a portal diversion.

Budd-Chiari Syndrome↗
PubMed1993

Oesophagectomy by a transhiatal approach or thoracotomy: a prospective randomized trial.

A prospective randomized trial of 67 patients undergoing oesophagectomy by either a transhiatal approach or right-sided thoracotomy was conducted over a 40-month period. In 32 patients the approach was transhiatal and 35 had a thoracotomy; the groups were well matched before operation. There were two hospital deaths in patients having the transhiatal oesophagectomy and three in those undergoing thoracotomy. Blood transfusion, intensive care stay and overall time of hospitalization were not significantly different between the two groups. There was no difference in the postoperative morbidity rate and, in particular, the incidences of pulmonary complications were similar (19 per cent for transhiatal oesophagectomy, 20 per cent for thoracotomy) with anastomotic fistula in 6 and 9 per cent respectively. The median (range) operating time was significantly longer in patients having thoracotomy (6 (3.5-9.5) versus 4 (3-8) h). Long-term survival was unaffected by the type of operation performed or addition of preoperative chemotherapy or radiotherapy. Nodal status was a significant prognostic factor within but not between the two groups. It is concluded that oesophagectomy by a transhiatal route or right thoracotomy are equally effective surgical options for treatment of squamous cell oesophageal cancer.

Aged↗
PubMed1993

Gastrointestinal surgical emergencies following kidney transplantation.

This study reports major gastrointestinal complications in a group of 416 patients following kidney transplantation. Three hundred and ninety-nine patients received a cadaveric kidney while the other 17 received a living related organ. The immunosuppressive regimen changed somewhat during the course of the study but included azathioprine, prednisolone, antilymphocyte globulin, and cyclosporin. Perforations occurred in the colon (n = 6), small bowel (n = 4), duodenum (n = 2), stomach (n = 1), and esophagus (n = 1). There were five cases of acute pancreatitis, four of upper gastrointestinal and two of lower intestinal hemorrhage, two of acute appendicitis, one of acute cholecystitis, one postoperative mesenteric infarction, and two small bowel obstructions. Fifty percent of the complications occurred while patients were being given high-dose immunosuppression to manage either the early postoperative period or episodes of acute rejection. Ten percent of the complications had an iatrogenic cause. Of the 31 patients affected, 10 (30%) died as a direct result of their gastrointestinal complication. This high mortality appears to be related to the effects of the immunosuppression and the associated response to sepsis. Reduction of these complications can be achieved by improved surgical management, preventive measures, prompt diagnosis, and a reduced immunosuppressive protocol.

Adolescent↗
PubMed1993

Transhiatal esophagectomy using a ring dissector.

Subtotal esophagectomy may be performed without thoracotomy by transhiatal dissection. We describe an alternative to the classical technique of transhiatal manual blunt dissection of the esophagus using a ring dissector, which allows a less traumatic dissection of the esophagus above the carcinoma of the esophagus. This instrument, designed for this particular purpose, produces a rapid and clean blunt dissection.

Equipment Design↗
PubMed1992

Femoropopliteal artery occlusion: clinical experience with the Kensey catheter.

In 25 patients, 12 with acute-subacute and 13 with chronic extensive femoropopliteal artery occlusions (mean length, 8 cm), a prospective study was performed after application of the Kensey catheter and subsequent performance of percutaneous transluminal angioplasty (PTA). Passage through the occlusion with the Kensey catheter failed in five patients because of the presence of dissections. As confirmed at angiography, free flow through the obstruction and the runoff bed could be restored with the Kensey catheter, guide wires, balloon dilation, and thrombus aspiration and/or thrombolysis in 24 of the 25 patients (96%). In five patients, peripheral embolisms occurred after application of the Kensey or balloon catheter. Cumulative patency rates, according to findings of a noninvasive examination, were 80% at 3 days, 59% at 6 months, and 38% at 12 months after performance of the combined interventions. Thus, the results obtained with use of this new device have not proved superior to previously reported results with conventional PTA.

Aged↗