Adult respiratory distress syndrome.
Explore the source record for details and available documents.
Animals↗
Biomedical subjects
H J Sugerman
Publications and source records attributed to H J Sugerman.
Pulmonary function in morbid obesity.
Morbid obesity is not infrequently associated with severe respiratory impairment. In our experience approximately 10 per cent of morbidly obese patients who underwent gastric surgery had severe respiratory impairment. Respiratory insufficiency of obesity can be divided into two primary breathing disorders: the obstructive sleep apnea syndrome (SAS) and the obesity hypoventilation syndrome (OHS). In its most severe form, when both SAS and OHS are present, it is called the Pickwickian syndrome. In our series 59 morbidly obese patients with respiratory insufficiency secondary to obesity underwent gastric surgery for weight reduction. Fourteen had OHS, 19 had SAS and 26 had both. Of these, two patients died of postoperative complications and one died at five weeks with an inconclusive autopsy, totalling an operative mortality rate of 3.4 per cent and a total mortality of 5.1 per cent. In our overall experience morbidly obese patients lost 67 per cent of excess weight after gastric procedures. In conclusion, surgically induced weight loss will markedly improve or correct respiratory insufficiency secondary to obesity. It will improve arterial oxygenation, minimize CO2 retention, expand lung volumes, correct polycythemia, and reduce apnea frequency. The magnitude of changes in these variables is clinically significant. Therefore, respiratory insufficiency of obesity should be considered a major indication for an aggressive approach to weight reduction. The jejunoileal bypass and unbanded gastroplasty operations have an unacceptable incidence of complications or failure, respectively. There is a high degree of recidivism following dietary programs. Sweets eaters will not do well with a gastroplasty procedure. Gastric bypass for individuals addicted to sweets or the vertical banded gastroplasty for "gorgers" are currently our procedures of choice and are associated with the average loss of two thirds of excess weight and correction of breathing problems associated with morbid obesity.
Anesthesia↗
Operative choices in morbid obesity.
Explore the source record for details and available documents.
Humans↗
Ibuprofen and methylprednisolone in a pig Pseudomonas ARDS model.
The effects of ibuprofen (I) and methylprednisolone (M) were studied in the Pseudomonas porcine model of adult respiratory distress syndrome (ARDS). Four groups of animals were anesthetized and ventilated with 0.5 FIO2, 5 cm PEEP, and 20 cc/kg tidal volume: a control group given saline alone; Pseudomonas infusion alone (P); Pseudomonas with ibuprofen (I), 12.5 mg/kg given at 20 and 120 min; and P with methylprednisolone (M), 30 mg/kg given at 20 and 120 min. We compared the alteration in pulmonary hemodynamics with the alteration in the plasma concentration of thromboxane (TxB2) and 6-keto PGF1 alpha in the treated and untreated groups. Hemodynamic parameters measured included the pulmonary (PAP) and systemic (SAP) arterial pressures, cardiac index (C1), thermal-cardiogreen extravascular lung water (EVLW), and PaO2. Albumin Flux was measured by a gamma scintigraphic method (slope index; SI). P produced a dramatic increase in PAP (P less than 0.05) with a progressive increase in EVLW and SI (P less than 0.05) and fall (P less than 0.05) in PaO2, CI, and SAP. The acute pulmonary hypertension was associated with a significant rise in TxB2 and 6-keto PGF1 alpha in the Pseudomonas group. I effectively blocked the elevation of TxB2 and caused a significant but transient improvement in PAP and rise in PaO2. Albumin flux and water leak as measured by SI and EVLW were not affected by ibuprofen. M reduced the elevation of TxB2 and 6-keto PGF1 alpha but failed to block these prostaglandins significantly.(ABSTRACT TRUNCATED AT 250 WORDS)
6-Ketoprostaglandin F1 alpha↗
Gastric duplication cyst communicating with aberrant pancreatic duct: a rare cause of recurrent acute pancreatitis.
An 18-year-old patient who had recurrent attacks of acute pancreatitis was found on endoscopic retrograde cholangiopancreatography to have an aberrant pancreatic duct which communicated with a juxtagastric cyst. Excision of a gastric antral duplication cyst and the aberrant pancreas was curative. Of the five previously reported cases, none of which had endoscopic retrograde cholangiopancreatography before surgery, all but one required multiple operations before the correct diagnosis was made.
Acute Disease↗
Incomplete small bowel obstruction by the Garren-Edwards gastric bubble necessitating surgical intervention.
A 39-yr-old woman was treated with Garren-Edwards gastric bubble, a new nonsurgical device for the treatment of obesity. The patient did well for 31/2 months before presenting with a partial small bowel obstruction caused by a spontaneously deflated bubble. After several days of observation and therapeutic maneuvers, a partially deflated bubble was removed surgically. Although the patient had had previous abdominal surgery, she had no adhesions that were considered contributory to the obstructive process at surgery; the deflated bubble did not deflate enough to traverse the distal ileum. This case represents the first case of bowel obstruction by this device in a patient with a "normal" intestinal tract. Patients considering placement of a Garren-Edwards gastric bubble must be fully informed of this potential complication even when there has been no prior abdominal surgery.
Adult↗
Continuous absorbable vs interrupted nonabsorbable fascial closure. A prospective, randomized comparison.
A prospective, randomized comparison of continuous, absorbable, No. 2, coated, polyglycolic acid suture (Dexon-Plus) vs interrupted, nonabsorbable, No. 28 monofilament stainless steel wire suture was performed in 105 patients for midline fascial closure following gastric surgery for morbid obesity. The preoperative weight, sex distribution, and type of operation were not significantly different between the two groups. No significant difference was found in the wound complication rate between the two closure methods (7/54 for wire and 8/51 for polyglycolic acid). There were one dehiscence and five incisional hernias in the wire group and five hernias in the polyglycolic acid group. Continuous closure was accomplished in significantly less time (21 +/- 8 minutes) than interrupted closure (43 +/- 19 minutes). An additional 121 patients underwent continuous No. 2 polyglycolic acid fascial closure after the end of the randomized trial, with 13 wound complications, including ten incisional hernias. In conclusion, continuous, absorbable suture closure for laparotomy wounds is recommended for its economy of time and the lack of significant difference from an interrupted, nonabsorbable wound closure.
Adult↗
True splenic cyst associated with hypersplenism.
Explore the source record for details and available documents.
Adult↗
Effects of ibuprofen on a pig Pseudomonas ARDS model.
The effects of ibuprofen (I) were studied in the Pseudomonas (P) porcine ARDS model. Pigs, 14-26 kg (5 in each group), were anesthetized and ventilated with 0.5 FiO2 and 5 cm H2O PEEP. A control (C) group received saline only, a second group was given P, 1 X 10(8) org/ml at 0.3 cc/20 kg/min, and a third group was given P followed by 12.5 mg I at 20 and 120 min. Pulmonary arterial (PAP), wedge (PWP) and systemic arterial pressures, cardiac output (CO), and thermal-cardiogreen extravascular lung water (EVLW), thromboxane (TxB2), 6-keto-PGF1 alpha, PaO2, PaCO2 were determined every 30 min. Albumin flux was measured with scintigraphic determination of lung:heart radioactivity ratios versus time, called slope index (SI). At 3 hr, P produced marked (P less than 0.05) increases in PAP (18 +/- 7 to 37 +/- 2 mm Hg), TxB2 (471 +/- 513 to 9216 +/- 3615 pg/ml), 6-keto-PGF1 alpha, EVLW (6.4 +/- 1.4 to 14.6 +/- 5.7 mg/kg), and SI (0.4 +/- 0.2 to 1.7 +/- 0.5 X 10(-3) U/min) with decreases in PaO2 (214 +/- 47 to 101 +/- 41 torr), CO and SAP. Ibuprofen caused a rapid clearing of TxB2 and 6-keto-PGF1 alpha associated with a transient decrease in PAP; PaO2 was considerably improved compared to P; however, CO, SAP, EVLW, and SI were unaffected. Prostaglandin blockage temporarily ameliorated the pulmonary hypertension and markedly improved oxygenation in this porcine septic ARDS model, but failed to alter increased permeability, confirming other studies that the increased pulmonary shunt in ARDS is not only dependent upon capillary leak.
6-Ketoprostaglandin F1 alpha↗
Prospective study of catheter replacement and other risk factors for infection of hyperalimentation catheters.
To determine risk factors for infection of hyperalimentation catheters, we prospectively studied 169 catheter systems (88 patients) by using a semiquantitative culture technique. Infection occurred in 24 (14%) catheters (16 patients), was inversely proportional to the number of previous catheters inserted by the operator (P less than .02), and was proportional to the interval between admission and catheter insertion (P less than .0005). Catheter replacement over a guidewire was no more likely to be associated with infection than was a de novo percutaneous insertion at another site (P = .6). Using a proportional hazards model, we estimated the risk of infection per day to be 1.3 times greater for a catheter if the patient had been hospitalized 50 days instead of seven days, and 3.8 times greater if the patient had a Swan-Ganz catheter at the time of insertion.
Adult↗
Selective drainage for pancreatic, biliary, and duodenal obstruction secondary to chronic fibrosing pancreatitis.
Twenty-eight patients underwent surgery for intractable pain, duodenal or extrahepatic biliary obstruction secondary to chronic pancreatitis. Eleven had pancreatic duct obstruction alone, six biliary obstruction alone, seven combined pancreatic and biliary, two combined biliary and duodenal, one combined pancreatic and duodenal, and one simultaneous pancreatic, biliary, and duodenal obstruction. Pancreatitis was secondary to alcohol in all but one case. The following operations were performed: longitudinal pancreatojejunostomy (20), choledochoduodenostomy (8), choledochojejunostomy (7), cholecystojejunostomy (1), and gastrojejunostomy (4). Of the 20 patients with pancreatic duct drainage, pain relief was complete in 11 and partial in six. Initial incomplete relief of pain, or recurrence, stimulated further diagnostic procedures, leading to improvement or correction of the problem in five patients. A significant (p less than 0.01) fall in alkaline phosphatase (935 +/- 228 to 219 +/- 61 U/L) occurred following surgery. One patient was subsequently found to have pancreatic carcinoma. Two patients were lost to follow-up and four patients died (one perioperative and three late). In conclusion, the possibility of pancreatic, biliary, and duodenal obstruction must be considered in symptomatic patients with chronic pancreatitis. Surgery must be individualized. Drainage procedures, either alone or in combination, are associated with a low morbidity and improved clinical condition and may be preferable to resection in the surgical management of these patients.
Adult↗
Gastric surgery for respiratory insufficiency of obesity.
Morbid obesity is often associated with severe respiratory insufficiency, commonly known as the pickwickian syndrome. This can be divided into the following two primary breathing disorders which can affect patients alone or in combination: the obstructive sleep apnea syndrome (SAS); and the obesity-hypoventilation syndrome (OHS). Thirty-eight (14 percent) of 263 morbidly obese patients with respiratory insufficiency of obesity underwent gastric surgery for weight reduction. Ten had OHS, nine has SAS, and 19 had both. Of these patients, one died of postoperative complications, one died at five weeks with an inconclusive autopsy, one was lost to follow-up, and the time since surgery was too short (less than three months) in three. A total of 30 patients lost 45 +/- 25 percent (p less than 0.0001) of excess body weight within 3 to 12 months following surgery, when repeat pulmonary studies were done. Most patients continued to lose additional weight until two years, when they had lost 62 +/- 26 percent of excess weight. Nine patients failed initial surgery (gastroplasty); seven of these were successfully converted to gastric bypass. Weight loss was associated with a significant decrease in the percentage of sleep apnea from 44 +/- 15 to 8 +/- 11 (p less than 0.0001). In patients with OHS, the arterial oxygen pressure (PaO2) increased from 53 +/- 9 to 68 +/- 11 mm Hg (p less than 0.0001), and the arterial carbon dioxide tension decreased from 51 +/- 7 to 41 +/- 4 mm Hg (p less than 0.0001). Pulmonary function tests in the patients with OHS revealed significant increases, as a percentage of predicted normal, in the forced vital capacity, forced expiratory volume in one second, expiratory reserve volume, functional residual capacity, and total lung capacity. Secondary polycythemia, defined as a hemoglobin level greater than 16 g/dl associated with a PaO2 less than 60 mm Hg, was noted in 13 of 29 patients with OHS. This fell from 16.9 +/- 1.1 to 14.9 +/- 1.7 g/dl (p less than 0.001) after weight loss and improved pulmonary function.
Adult↗
Comparison of indium 111-labeled platelets v leukocytes in a pyogenic abscess.
This study sought to determine which blood component, WBCs or platelets, is the more specific indicator of an abscess and where each localizes. An abscess was created using stool in the hind limb of dogs. After 24 hours, one group was given autologous indium 111-labeled platelets and another group was given autologous indium 111-labeled WBCs. Blood, abscess fluid, infected operative control muscle tissue, and nonoperative control muscle tissue were counted for radioactivity 24 hours after administration of the labeled cells. There was significantly (P less than .001) less WBC radioactivity in blood and more within abscess fluid compared with platelets. The highest platelet activity occurred in muscle tissue adjacent to the abscess (P less than .002) compared with platelet activity in abscess fluid or control muscle tissue. The unwanted high platelet blood background activity and the desirable high concentration of WBC radioactivity within the abscess fluid makes the latter the preferential radionuclide imaging agent.
Abscess↗
Recurrent midline hernial repair.
Explore the source record for details and available documents.
Abdominal Muscles↗
Endoscopic dilation of late stomal stenosis. Its use following gastric surgery for morbid obesity.
We have observed 16 cases of stomal stenosis occurring late after gastric surgery for morbid obesity. In one patient no stoma was apparent in the pouch on radiographic or endoscopic examination and reoperation was required for complete obstruction. We dilated stenoses in the remaining 15 patients. Stenosis in the three earliest patients in our series were dilated with Eder-Puestow dilators. All subsequent patients have received endoscopic dilation with pneumatic balloon catheters. Ten patients remain asymptomatic following dilation. Two patients have occasional vomiting, which is ameliorated by metoclopramide hydrochloride, despite a sufficiently patent stoma. Two patients with a torsion of the stoma received no benefit from dilation, and one patient with a sufficiently patent stoma has experienced frequent vomiting. Surgery has been repeated in the latter three patients. The technique of endoscopic pneumatic balloon catheter dilation is a safe and effective means of dilating stomal stenoses occurring late after gastric surgery for morbid obesity.
Catheterization↗
Failed gastroplasty for morbid obesity. Revised gastroplasty versus Roux-Y gastric bypass.
Forty-six percent of 122 gastroplasties for morbid obesity failed. This included a failure rate of 71 percent for a single staple line without stomal reinforcement, 37 percent for a double staple line and a central stoma reinforced with 2-0 polypropylene, and 42 percent for the Gomez gastroplasty. Revisional procedures were performed in 44 patients. Ten underwent revision of a failed gastroplasty using a gastrogastrostomy and 34 had conversion to a Roux-Y gastric bypass. Patients who had revisional gastroplasty as a second procedure had a significantly higher failure and complication rate than those converted to gastric bypass. Four of these 10 patients were subsequently converted to gastric bypass as their third weight reduction procedure. Conversion of a failed gastroplasty to a Roux-Y gastric bypass is a difficult procedure that carried a significantly higher complication rate in our study than that of a group of 46 patients who underwent a primary gastric bypass procedure. Of 26 patients followed for more than 1 year after conversion to Roux-Y gastric bypass, the average weight loss was 66 +/- 18 percent of their excess body weight. This was comparable to 16 patients who had undergone a primary gastric bypass more than 1 year previously and had lost 69 +/- 17 percent of their excess body weight.
Clinical Trials as Topic↗
Gamma scintigraphic analysis of albumin flux in patients with acute respiratory distress syndrome.
Computerized gamma-scintigraphy provides a new method for the analysis of albumin flux in patients with pulmonary permeability edema. In this technique, 10 mCi of 99mTc -tagged human serum albumin is administered and lung:heart radioactivity ratios are determined. This ratio remains constant unless there is a leak of albumin, when a rising ratio with time, called the "slope index" (SI), is seen. Thirty-five scintigraphic studies were obtained in 28 patients by means of a portable computerized gamma-camera. Thirteen of these patients had clinical evidence of the acute respiratory distress syndrome (ARDS) and six had or were recovering from left ventricular induced congestive heart failure (CHF). Five of the patients with CHF and pulmonary capillary wedge pressure (PCWP) below 30 mm Hg had normal scintigraphic studies. One patient in florid CHF with a PCWP of 40 mm Hg had a positive SI of 1.6 X 10(-3) U/min. The patients with ARDS were found to have significantly higher SIs than patients who did not have, or had recovered from, ARDS. The arterial:alveolar oxygen tension ratio (a/A)O2 was 0.30 +/- 0.14 in patients with positive SIs while receiving 11.0 +/- 6.8 m H2O positive end-expiratory pressure (PEEP). Both the (a/A)O2 and level of PEEP were significantly (P less than 0.01) worse in these patients than in patients with normal SIs. Positive SIs were present from 1 to 8 days following the apparent onset of ARDS in seven studies in five patients. Recovery of gas exchange was associated with a return to a normal SI in four patients. In conclusion, computerized gamma-scintigraphy was a sensitive, noninvasive tool for the detection of a pathologic increase in pulmonary protein flux. Positive scintigraphic findings were associated with significantly impaired gas exchange. The method documented that the leak of albumin in patients with ARDS may last for days but resolves with recovery.
Evaluation Studies as Topic↗
Failure of methylprednisolone, ibuprofen, or prostacyclin to reduce HCl-induced pulmonary albumin leak in dogs.
The purpose of this study was to examine the effects of methylprednisolone (MP), ibuprofen (I), and prostacyclin (PGI2) pretreatment on cardiopulmonary hemodynamics, arterial oxygenation, and pulmonary alveolar-capillary membrane permeability, measured with a gamma-scintigraphic technique, after acid instillation in the dog. All animals were placed on their right side and 2 ml/kg 0.1 N HCl was instilled into the endotracheal tube. Five untreated control dogs showed a significant (p less than 0.05) rise in slope index (SI), a scintigraphic measurement of pulmonary albumin flux, 30 minutes after acid injury. After 120 minutes there was a significant rise in mean pulmonary arterial pressure (PAP) and pulmonary vascular resistance (PVR) and a decrease (p less than 0.05) in cardiac output (CO) and PaO2. Two groups of five dogs each were pretreated with MP (30 mg/kg) and I (12.5 mg/kg), respectively. Thirty minutes after acid instillation both groups showed a significant rise in the SI, which was significantly greater than the values in the control animals in the case of MP. By 120 minutes after acid injury all changes in PAP, PVR, PaO2, and CO were not significantly different from those of control animals with the exception of the I group, which resisted any change in CO throughout the study. Another group of five dogs were pretreated with a constant infusion of PGI2 (3 micrograms/kg/min) starting 75 minutes before acid instillation. PGI2 produced a significant increase in CO that was also greater (p less than 0.05) than the CO in control animals before instillation of HCl. Pre-HCl SI in the dogs treated with PGI2 was slightly, but significantly, increased over control dogs. The SI and CO remained significantly higher than values in control animals 30 minutes after acid injury. The SI remained significantly higher than that of control animals at 120 minutes. After 2 hours changes in PAP, PVR, PaO2, and CO were without significant difference from those of control animals. These data support the conclusion that PGI2, I, or MP are not effective therapy for acid aspiration and that PGI2 and I may worsen the protein leak by increasing flow across the damaged capillary membrane.
Albumins↗