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J L Munson

Publications and source records attributed to J L Munson.

34 records · Page 2Linked to original sources
PubMed1990

Endoscopic retrograde cholangiopancreatography in the preoperative diagnosis of pancreatic neoplasms associated with cysts.

Neither computed tomography (CT) nor ultrasonography reliably distinguishes neoplastic from non-neoplastic pancreatic cysts. More invasive tests such as angiography or biopsy fail to differentiate these lesions in up to a third of patients. Because appropriate treatment differs greatly for these two classes of lesions, the clinician requires a more accurate means of confirming or excluding neoplasia. In an effort to refine the preoperative diagnosis of pancreatic cysts and evaluate the utility of endoscopic retrograde pancreatography (ERCP), we evaluated 11 patients with proven pancreatic neoplasia associated with cysts who underwent preoperative ERCP and CT scanning. Four patients had microcystic cystadenomas, two had a mucinous cystadenoma, one had a mucinous cystadenocarcinoma, and four had adenocarcinomas associated with cysts. CT identified a pancreatic cystic lesion in each patient. In all patients, ERCP showed either focal irregular narrowing, occlusion, or displacement of the main pancreatic duct at the corresponding location without the ductal changes of chronic pancreatitis. This helped to preoperatively differentiate these lesions from pseudocysts, hastening appropriate operation, obviating further testing and consultation, and aiding the intraoperative surgical strategy.

Adult↗
PubMed1989

Management of pancreatic fistulas.

Conservative management of pancreatic fistulas resulting from trauma, operation for tumor, or operation for pancreatitis has met with variable success. To assess optimal management strategies and outcome, we reviewed the records of 35 patients with external pancreatic fistulas (26 patients), pancreatic ascites (6 patients), or pancreatic pleural effusion (3 patients). Treatment included no operation in 5 patients, oversewing of the fistula in 7 patients, internal drainage in 11 patients, and resection in 12 patients. One (3%) postoperative death occurred. The overall rate of operative success was 83% (25 patients). The incidence of recurrent fistulas was about the same regardless of the procedure. Patients treated successfully without operation did not have pancreatitis as an underlying disease. Patient selection is of great importance in the decision to resect or to drain and is based in part on imaging the pancreatic duct and fistula.

Adult↗
PubMed1989

Lithotripsy for bile duct stones.

Fragmentation of bile duct stones by mechanical, electrohydraulic, and laser intraluminal lithotripsy has greatly facilitated the ability to remove stones that are otherwise difficult to remove by standard manipulative techniques. Even these approaches fail when stones lack access or are impacted within the biliary tree. Extracorporeal shock-wave lithotripsy (ESWL) was evaluated in the United States in a multicenter trial with 56 patients. Stone fragmentation occurred in 91 percent of patients and duct clearance in 79 percent. Adjunctive procedures were used in 54 percent. Two ESWL treatments were required for fragmentation in 28 percent. Complications were mild and relatively infrequent. Hemobilia (8 percent), gross hematuria (6 percent), and biliary sepsis (4 percent) occurred less frequently than expected. There were no deaths during the 1 to 31 days of hospitalization (mean 9 days). We conclude that ESWL is a safe and effective adjunct to the treatment of difficult-to-remove bile duct stones under the conditions observed in this trial.

Bile Duct Diseases↗
PubMed1989

Extracorporeal shock-wave lithotripsy of bile duct calculi. An interim report of the Dornier U.S. Bile Duct Lithotripsy Prospective Study.

A multi-institutional study to evaluate the efficacy, clinical application, and safety of extracorporeal shock-wave lithotripsy (ESWL) with the Dornier HM-3 or HM-4 lithotripter for bile duct calculi (BDC) was initiated in September, 1987. Symptomatic patients who entered into this prospective trial had BDC in the common bile duct and/or the intrahepatic, cystic or lobar ducts of the liver that were inaccessible or untreatable by papillotomy or percutaneous stone extraction. The study excluded gallbladder stones. Nasobiliary (54.4%) or transhepatic catheters (10.5%) and T-tube or cholecystostomy tubes (17.5%) or combinations (14.0%) permitted access for radiographic contrast to allow fluoroscopic monitoring of stone position and fragmentation. Exclusion criteria included pregnancy, failure to localize the stone, disturbances of coagulation, pacemakers, or vascular aneurysms or large bones that lie in the focal axis of the shock waves. Eleven institutions treated 42 patients (23 male, 19 female) with BDC; age range was 25 to 95 years (mean +/- SD, 73.5 +/- 13.8) and ASA risk category was 1 to 4 (mean, 2.3 +/- 0.8). Fourteen patients (33.3%) had a single BDC; 28 had 2 to 8 stones (mean, 2.7 +/- 1.8) ranging in size from 6 mm to 30 mm (mean, 18.5 +/- 6.4). The majority (66.7%) of patients were postcholecystectomy. The 42 patients received 57 ESWL treatments consisting of 600 to 2400 shocks per treatment (mean, 1924 +/- 289) at 12 to 22 kV (mean, 18.5 +/- 1.9) administered over 20 to 125 minutes (mean, 52.9 +/- 20.8). General anesthesia was used in 32% of the treatments; the majority were treated with epidural or regional block (42.1%), local infiltration (28.1%), or intravenous sedation (38.6%). Fifteen patients (35.7%) required two ESWL treatments. Stone fragmentation occurred in 94.6% of evaluable patients and in 90.4% of ESWL treatments, respectively; however, BDC fragments remained in 59.5% of patients 24 hours after treatment (diameter less than or to 3 mm, 12%; 4 to 9 mm, 16%; greater than or equal to 10 mm, 68%). Some patients (50%) required adjunctive procedures to achieve stone removal that included endoscopic extraction (n = 10; 47.6%), biliary lavage (n = 8; 38.1%), endoscopic bile duct prosthesis (n = 1; 4.8%), and operation (n = 2; 9.5%). ESWL treatment complications during hospitalization were observed in 15 patients (35.7%) and were present in four (9.5%) at discharge. Complications included macrohematuria (5%), biliary pain (15%), biliary sepsis (5%), hemobilia (10%), ileus (2.5%), and adverse pulmonary changes (7.5%). One patient developed pancreatitis before ESWL at ERCP that resolved prior to discharge.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗
PubMed1989

Cystadenoma and cystadenocarcinoma of the pancreas.

During the period 1963 to 1988, we treated 45 patients with cystic neoplasms of the pancreas. The patients were divided into group 1, which included 26 patients treated between 1963 and 1983, and group 2, which included 19 patients treated between 1984 and 1988. The rate of resection for cystadenoma was 67% for group 1 (n = 15) and 100% for group 2 (n = 11). The operative mortality rate was 0% for both groups. Pathologically, 17 patients (69%) had serous cystadenoma and nine (31%) mucinous adenoma. Except for 5 of the 15 patients from group 1 who died of other causes, all patients are healthy. The resection rate for cystadenocarcinoma was 36% for group 1 (n = 11) and 100% for group 2 (n = 8). In 2 patients from group 1 and 1 patient from group 2, the tumors had been diagnosed previously as benign by operative biopsy of the cyst wall. There was no operative mortality in either group. Cystic neoplasm was suspected from the results of ultrasonography and computed tomography in 70% of the patients in group 2. In 2 patients (25%), the preoperative diagnosis of pseudocyst associated with chronic pancreatitis was made. Adenocarcinoma was diagnosed in 3 patients by needle biopsy and cytologic examination of pancreatic juice. Eighty-two percent (9 patients) of group 1 died of recurrent carcinoma; 2 patients were alive without disease at 5 and 8 years. Thirty-eight percent (3 patients) of patients in group 2 died of recurrent carcinoma, two patients died of other causes, and 3 patients are still alive.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1989

Enucleation of intrahepatic biliary cystadenomas.

Enucleation is our technique of choice for the management of intrahepatic benign biliary cystadenomas. Our experience in four patients demonstrates the usefulness of this method, especially in large centrally located lesions. Primary application of this technique should minimize the substantial mortality and early and late morbidity associated with biliary cystadenomas.

Adult↗
PubMed1987

Pancreatoduodenectomy in the management of chronic pancreatitis.

The records of 73 consecutive patients who underwent pancreatoduodenectomy for chronic pancreatitis between 1960 and 1985 were reviewed. The median size of the pancreatic duct was 5 mm. Two operative deaths (2.7%) occurred early in the series. Eighty-eight percent, 86%, and 79% of the patients had improvement in pain at six months, two years, and five years, respectively. Diabetes was present preoperatively in 25% of patients and postoperatively in 37%, 45%, and 69% of patients at six months, two years, and five years, respectively. Pancreatic enzyme preparations were used preoperatively by 26% of patients; this use increased to 75% by five years. Only four of 17 late deaths could be related to diabetes or malnutrition. In most patients, pancreatoduodenectomy achieves long-term pain improvement and permits return to normal activities. Selection of patients is important to decrease the late morbidity and mortality.

Adult↗
PubMed1987

Cystic neoplasms of the pancreas.

From 1963 to 1983, 26 patients with cystic neoplasms of the pancreas were treated at the Lahey Clinic, Burlington, Mass. Cystadenoma (15 patients) was more common than cystadenocarcinoma (11 patients). Preoperative symptoms, such as abdominal pain, were present for as long as 18 years before diagnosis. The mean size of cysts was 7 cm. Distal pancreatectomy, the most common operation, was performed in ten patients. Eight of the 11 patients with cystadenocarcinoma had metastatic disease at the time of surgical exploration. There was one postoperative death (3.8%). Patients with cystadenocarcinoma had an adjusted median survival time after operation of 6.0 months. The long prodrome in many of the cancer patients suggests that benign cystadenomas, particularly of the mucinous type, may undergo malignant degeneration. Benign cystadenoma seems unlikely to recur after adequate resection. Whenever possible, complete excision of cystadenoma and cystadenocarcinoma is the procedure of choice.

Actuarial Analysis↗
PubMed1987

Carcinomas arising in cystic conditions of the bile ducts. A clinical and pathologic study.

Thirty patients with cystic disease of the bile ducts operated on between 1965 and 1985 were reviewed. Three patients (10%) had a synchronous adenocarcinoma, and in three patients (10%) a metachronous carcinoma developed for a total incidence of malignancy of 20%. All patients died within 1 year of the diagnosis of malignancy. Of 19 benign cysts available for pathologic examination, one third had proliferative epithelial changes, and in two of these patients a metachronous carcinoma developed. Goblet cell metaplasia was prominent in four patients. This suggests the possibility that dysplastic changes and metaplasia of the epithelium could give rise to carcinoma. Resection of benign cysts of the bile ducts is favored, when feasible, in an attempt to decrease the incidence of malignancy.

Adenocarcinoma↗
PubMed1986

Management of bile duct cysts in adults.

In 31 adult patients with bile duct cysts seen at the Lahey Clinic (Burlington, Mass) during a 20-year period, the median age at time of initial therapy at Lahey Clinic was 34 years. Abdominal pain was the most common presenting symptom, followed by jaundice and fever. The 31 patients underwent a total of 86 biliary tract procedures, of which 37 were performed at Lahey Clinic. Internal drainage was the most common operation, but it frequently resulted in recurrent symptoms requiring reoperation. Cyst excision was associated with a significantly lower incidence of recurrent cholangitis and need for reoperation and was not associated with increased operative mortality. Cystic disease was frequently associated with other hepatobiliary diseases. Biliary carcinoma occurred in five (16%) of our patients, and late deaths from biliary-related disease occurred in seven patients (22%). When technically possible, cyst excision is the treatment of choice.

Adolescent↗
PubMedDate not supplied

Bile duct injury during laparoscopic cholecystectomy: mechanism of injury, prevention, and management.

Although several studies have shown a low incidence of bile duct injuries during laparoscopic cholecystectomy, concerns remain because of the sustained increase in the number of referrals for biliary reconstruction after the procedure. Twenty-one patients have been referred to our institution because of major bile duct injuries after laparoscopic cholecystectomy. The injury was recognized during the laparoscopic procedure in only 6 of the 21 (29%). Nineteen patients underwent hepaticojejunostomy at least once, one patient required hepaticojejunostomy and repair of a choledochoduodenal fistula, and one patient needed repair of a biliary colonic fistula. Hepaticojejunostomy above the bifurcation was required in 10 patients (50%), at the bifurcation in 3, and below the bifurcation in 7. Nine of the eleven patients in whom the initial repair was performed at the local hospital presented with early stricture (median 7 months). The common denominator of the development of bile duct injuries during laparoscopic cholecystectomy is the failure to identify the structures of the triangle of Calot. Specific steps during laparoscopic cholecystectomy to avoid bile duct injuries are described. Expertise in hepatobiliary surgery appears to optimize results of biliary reconstruction.

Adolescent↗