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Biomedical subjects

J G Chandler

Publications and source records attributed to J G Chandler.

At least 19 recordsLinked to original sources
PubMed1991

Symptomatic congenital lesions of the alimentary tract in adults.

Congenital anomalies of the alimentary tract can evade detection into adulthood because they cause only moderate symptoms or they escape purview of a prepared observer. In other instances, evolution or copathogenesis may need to occur before the lesions become manifest. We have managed 17 of these patients presenting at ages 23 to 71 years. The median duration of symptoms was 5 years, ranging from 1 months to 23 years. Defects of foregut embryogenesis predominated (71%). We were able to establish the correct diagnosis before operating on nine patients, but three had already had a previous celiotomy for the same problem so a truly preoperative diagnosis was possible in only six (35%). The literature validates the dominance of foregut anomalies in adults. There is no older age limit that would exclude consideration of these lesions. Endoscopy, computerized tomography, and ultrasonography have greatly facilitated recognition, but our experience suggests that the principal obstacle to timely diagnosis is the reluctance to consider a congenital cause for an adult's symptoms.

Adult↗
PubMed1990

Nodular duodenitis and single duodenal nodules.

Duodenal nodules are an uncommon endoscopic finding generally thought to indicate duodenal inflammation. This study examines the incidence and histologic correlates of multiple and single duodenal nodules in 2,966 consecutive male patients who underwent esophagogastroduodenoscopy during the past five years. Five per cent had duodenal nodules. When two or more discrete nodules, with or without apical ulceration, were present, the finding was termed nodular duodenitis, which was seen five and one-half times more frequently than single nodules. There were 127 patients with nodular duodenitis (4.3%); seven had chronic renal disease and 33 (26%) had concomitant peptic ulcer disease. Biopsies showed either normal mucosa or histologic aberrations typical of nonspecific duodenitis. Single nodules were seen in only 23 patients (0.8%). Biopsies of these nodules revealed benign or malignant tumors in five instances and infrequently showed only normal mucosa. It is concluded that nodular duodenitis is a visually distinct, morphologic variant of nonspecific duodenitis bearing some yet-to-be-defined relationship to peptic ulcer disease. Single nodules are much less likely to represent duodenitis and, in fact, they have significant neoplastic potential, mandating biopsy whenever they are found.

Aged↗
PubMed1985

Factors affecting immediate and long-term survival after emergent and elective splanchnic-systemic shunts.

The course of 121 shunted cirrhotic patients, managed according to a prospective protocol over a period of 10 years, was analyzed to determine predictors of 30-day and long-term survival. Forty-five per cent of the patients underwent emergent decompression within 12 hours of active bleeding, and 34% of the shunts were selective. Logistic regression linked early mortality to bilirubin and blood-urea nitrogen (BUN) (p = 0.001), and long-term survival to the presence of preoperative ascites and higher levels of alkaline phosphatase (p = 0.027), but neither variable set was a more accurate predictor than Child Class. Emergency shunt patients had greater risk of early death, 44% vs. 17% for patients shunted electively (p = 0.001), but beyond 30 days, their Kaplan-Meier survival curves were identical. Independently, angiographic prograde portal flow was favorably associated with short-term (p = 0.003) but not prolonged survival. The presence of Mallory bodies, fatty metamorphosis, and acute periportal inflammation, alone or in combination, had no prognostic value. Continued post-operative alcohol ingestion jeopardized long-term survival (p = 0.017). Survival of nonalcoholics was enhanced by selective as opposed to total splanchnic decompression (p = 0.009).

Adolescent↗
PubMed1985

Bile duct carcinoma. Diagnosis and treatment.

Fifty-three patients were evaluated for carcinoma of the extrahepatic bile ducts at the University of Virginia from 1951 to April 1984. This population was retrospectively reviewed and 33 preoperative and postoperative variables were analyzed to evaluate the predictors of increased survival. No preoperative data, including symptoms, admitting laboratory data, or tumor location, predicted increased survival. Whipple resection yielded a median survival of 12 months; palliative resections, 1.5 months; and laparotomy, only 5.5 months; these differences were not statistically significant. Experience with six patients treated with internal radiation (iridium-192), plus as much as 4000 rads of external beam irradiation, suggests that this combination of radiation treatment may aid palliation.

Adenoma, Bile Duct↗
PubMed1985

Surgical complications of neuroblastoma resection.

Locally advanced neuroblastomas in infants and very young children often require intricate dissection to separate the tumors from the anatomic structures that they have enmeshed. The rationale for these procedures is based mainly on the premise that near-total resection is almost as effective as total extirpation, given favorable circumstances of age and stage. The principal reason for not undertaking or aborting such resections has been to avoid the fallacy of intentionally sacrificing vital structures, causing serious disability, in circumstances in which cure is either impossible or equally likely to accrue from a lesser procedure. This report describes five surgical mishaps, two of which resulted in postoperative deaths. The potential for these complications was greatest during resection of locally advanced tumors in small babies. We suspect that this hazard is more prevalent than its scarcity in the literature would suggest and that potential for unintended injury should be a prominent factor in the decision to proceed or desist with resection of a large neuroblastoma.

Child, Preschool↗
PubMed1985

Assessment of an implantable ileostomy sphincter.

A totally implanted, intermittently inflatable, silicone rubber cuff, reservoir, and control mechanism were evaluated for use as an artificial sphincter in 18 female beagle dogs that had undergone ileostomy. The dogs were divided into daily 8-hour occlusion, test, and always open, control, groups. Animals were evaluated daily for continence and peristomal irritation. Quantitative aerobic and anaerobic cultures, measurements of ileal accommodation, net fluxes of H2O, Na, K, and taurocholate, fecal fat loss, and urinary excretion of oral 58Co X B12 plus mucosal suction biopsies were done at 4, 12, 24, and 36 weeks. Eight hours of daily occlusion caused dependable continence without causing damage to the underlying or upstream mucosa and significantly reduced the incidence of peristomal erosion (6.8 +/- 0.8 days/dog-days X 100 versus 50.7 +/- 7 days/dog-days X 100 [+/- SEM] [p less than 0.001]). Occlusion also promoted anaerobic bacterial growth (9.00 +/- 0.41 logs versus 6.70 +/- 0.58 logs [p less than 0.001]). Test animals showed significant capacitance accommodation of the terminal ileum without incurring defects in ileal absorptive or secretory function. Gangrenous herniation of small bowel through an aperture formed by an intestinal loop adhering to the capsule surrounding the cuff, device failure, and fibrotic obstruction occurred sporadically as late as 29 weeks after implantation. The artifical sphincter was effective and was physiologically well tolerated, but its specific liabilities require further address.

Animals↗
PubMed1979

Selectivity of the distal splenorenal shunt.

The distal splenorenal shunt is less likely to provoke encephalopathy than conventional shunting procedures, and it may offer a survival advantage for certain cirrhotic individuals, presumably because of its selective nature. This study suggests that the distal splenorenal shunt, even with exceptional efforts to achieve portomesenteric-gastrosplenic (PM-GS) disconnection, is not nearly as selective as it originally was assumed to be. In 11 patients intraoperative pressure determinations showed a significant decrease in portal pressure after end-to-side distal splenorenal anastomosis and no restoration of portal pressure after PM-GS disconnection. Measurements of flow through the shunt were comparable to those reported for portacaval shunts, and shunt flow was not decreased significantly by PM-GS disconnection. Postoperative angiography showed some PM-GS collateral in 17 of 18 patients, and later angiographic studies showed a tendency for progressive collateral development and consequent loss of hepatopetal portal perfusion. The advantages of the distal splenorenal shunt must accrue from gradual, as opposed to abrupt, portal deprivation, rather than from lasting selectivity.

Blood Pressure Determination↗
PubMed1978

Alterations in intestinal structure, fat absorption and body weight after intestinal bypass for morbid obesity.

Eleven patients underwent jejunoileal bypass for morbid obesity. Serial intestinal biopsies were obtained prior to, and at timed intervals following, operation in both fasted and fat-fed states. Villus height increased asymptotically, reaching a plateau one year after operation, with an increase of 80 per cent in mean villus length. The postbypass body weight reached a plateau at 63.9 per cent of initial body weight and correlated linearly with villus height following an asymptotic curvilinear course. The time required to attain 90 per cent of total body weight loss was 15.9 months. A study of intestinal fat absorption at both the light microscopic and ultrastructural levels showed that the enlarged villi are lined along the entire villus by functionally mature epithelium capable of transporting lipid. Villus hypertrophy is an important mechanism in the plateauing of weight loss after jejunoileal bypass for morbid obesity.

Body Weight↗
PubMed1977

Mortality and morbidity of pancreatic injury.

Pancreatic trauma, regardless of etiology, has been consistently associated with a mortality of 20 percent and enormous morbidity. Twenty-five pancreatic injuries, including four solitary wounds of the pancreas, were analyzed to determine why pancreatic trauma should have such an adverse prognosis. Eleven patients were victims of blunt trauma and fourteen sustained gunshot wounds. There were no stab wounds. The important determinants of mortality were associated injuries to major vessels, wounds of the head of the gland, and failure to adequately control leaking exocrine secretion. All four deaths were directly related to massive hemorrhage; in two instances leakage of pancreatic juice was also implicated. With the exception of benign solitary blunt wounds of the pancreas to the body of the gland immediately ventral to the spinal column, an injury of the pancreas is evidence that the abdomen has been subjected to severe trauma, which predisposes the patient to a high mortality and morbidity. The pancreatic injury, interacting with other abdominal injuries, is likely to be a cause of significant mortality and to result in complications that will prolong the patient's hospitalization.

Abdominal Injuries↗
PubMed1977

Axillary, subclavian, and brachiocephalic vein obstruction.

The consequences of occlusion of a major upper extremity vein were evaluated in eight patients with effort thrombosis, ten with thrombosis secondary to intimal injury, six with extrinsic compression, and one hypercoagulable patient, all of whom were followed for an average of 4 years. Twenty-two patients had venography, which confirmed the diagnosis but often failed to define the proximal extent of obstruction. Thirteen patients had noninvasive hemodynamic studies which did not corroborate chronic morbidity, but which were valuable in assessing the effect os specific therapy. Twelve patients were treated with anticoagulants, and six had operative removal or bypass of the obstruction. Three patients had pulmonary emboli; two embolized while on anticoagulants and both died. Swelling, pain, prominent veins, and easy fatigability of the affected extremity were the late sequelae of occlusion. Chronic morbidity was more dependent on etiology than on initial treatment. Thrombosis secondary to intimal injury caused no persistent symptoms, whether treated with anticoagulants or not. Effort thrombosis was intermediate: three fourths complained that their affected arm tired easily and half had prominent veins or persistent swelling. All of those with obstruction secondary to extrinsic compression had easy fatigability. The majority also had concomitant swelling, pain, and prominent collaterals. Operative treatment produced objective improvement in venous outflow but often was unsuccessful in relieving symptoms, particularly in patients with obstruction from extrinsic compression.

Adolescent↗
PubMed1977

Hepatic intramitochondrial filaments in morbidly obese patients undergoing intestinal bypass.

The characteristics of hepatocyte intramitochondrial filaments (IMF's) were studied in 16 patients undergoing jejunal ileal bypass for morbid obesity. At the time of bypass, all of the liver biopsies showed varying degrees of steatosis and IMF's were present in 13 of the 16 operative specimens. The IMF's were most prominent in the periportal cells, whereas the intracellular lipid was concentrated in centrilobular cells. Midzonal hepatocytes were intermediate in both respects. The IMF'S were more abundant in biopsies showing moderate steatosis than in those with marked lipid accumulation in which the IMF's were limited to hepatocytes in juxtaposition to portal triads. The IMF's appeared to originate from mitochondrial cristae. When steatosis resolved 12 to 18 months after intestinal bypass the prevalence of IMF's diminished also. It is hypothesized that the presence of IMF's is ultrastructural evidence of an adaption to an altered metabolic environment which resolves when the inciting influence is removed.

Biopsy↗
PubMed1977

Misleading pneumoperitoneum.

Misleading pneumoperitoneum takes one of two forms: true pneymoperitoneum without peritonitis or pneumoperitoneum simulated by adventitious x-ray shadows. In both instances, the roentgenographic appearance of free intraperitoneal air proves to be a specious indication for laparotomy. Twenty-eight per cent of 29 patients with misleading pneumoperitoneum were subjected to operations that, retrospectively, might not seem absolutely necessary. The decisions to operate on patients with pneumoperitoneum without peritonitis were based on the amount of pneumoperitoneum roentgenographically visualized. The instances of pseudopneumoperitoneum had several common features. The diagnosis often was based only on x-ray films of the chest. Compatibility with clinical features was marginal; the radiolucency was often not truly at the apex of the diaphragm. Finally, the x-ray films, interpretation and working conditions frequently were suboptimal.

Adolescent↗
PubMed1975

A comparative appraisal of emphysematous cholecystitis.

There is ample evidence from this retrospective comparison to indicate that emphysematous cholecystitis does merit clinical distinction apart from acute cholecystitis. It is an acute infection of the gallbladder caused by a specific group of bacteria that may be aided by some aspect of local ischemia. Cholelithiasis does not seem to be a major factor in the pathogenesis of emphysematous cholecystitis, and this, in association with some dependence upon ischemia, may account for the predominance of this disease in males rather than females. Gangrene is a common feature of the pathologic process, and thus it is not surprising that the diagnosis of emphysematous cholecystitis implies a risk of gallbladder perforation that is five times that expected from ordinary acute cholecystitis. The key to identifying this disease is the plain abdominal roentgenogram which in most instances will make the diagnosis and provide an impetus for early operative intervention.

Cholecystitis↗