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Biomedical subjects

J Pickleman

Publications and source records attributed to J Pickleman.

At least 19 recordsLinked to original sources
PubMed2001

Laparoscopic repair of parapubic hernia.

Since the introduction of laparoscopic cholecystectomy in the late 1980s, video technology has continued to find new applications in the field of general surgery. Laparoscopic inguinal herniorrhaphy is touted by many to provide a minimally invasive approach to the most commonly performed general surgical procedure, possibly with a lower incidence of recurrence. Additionally, laparoscopic repair of an incisional hernia with synthetic mesh allows a tension-free procedure while potentially reducing the risk of complications such as wound and mesh infections by avoiding the use of large abdominal wall incisions through old surgical scars. The parapubic hernia is a rare form of incisional hernia resulting from the detachment of muscular attachments to the pubic bone. It is a diagnostic and therapeutic challenge that is often misdiagnosed and mismanaged. We have found the laparoscopic approach to the parapubic hernia to be a superior method of managing this often challenging condition.

Female↗
PubMed2001

Pancreaticogastrostomy following pancreaticoduodenectomy: review of 102 consecutive cases.

Disruption of the pancreatic anastomosis with resultant sepsis is the cause of nearly 50% of deaths following pancreaticoduodenectomy (PD). Traditionally, the pancreatic remnant is anastomosed to the jejunum. Pancreaticogastrostomy (PG) was introduced as an alternative by Waugh and Clagett in 1946 and by Park, Mackie, and Rhoads in 1967. The purpose of this retrospective review was to assess the safety of PG at a single institution. Between 1986 and 1998 a total of 102 patients underwent PG following PD. The indications for PD were periampullary carcinoma (n = 89), pancreatitis (n = 7), and miscellaneous (n = 6). Altogether, 80 patients underwent the traditional Whipple procedure and 22 the pylorus-preserving Whipple (PPW) procedure. The PG was performed by a single-layer invagination technique to the posterior gastric wall using interrupted silk sutures. Leaks from the pancreatic anastomosis were detected by measuring amylase in fluid obtained from surgically placed drains. Operative mortality was 3.9% (4/102). The cause of death was uncontrolled upper gastrointestinal hemorrhage, sepsis, pulmonary embolus, and cardiac failure secondary to myocardial infarction. The mean operating time was 6.8 hours. Blood transfusion was given in 43 patients (42%), and the mean amount of the transfusion was 2.6 units. Nonfatal complications occurred in 35 patients (34%), and included leaks from the pancreatic anastomosis in 9 (8.8%), leaks from the biliary-enteric anastomosis in 4 (3.9%), and gastric paresis 7 (6.9%). Other complications included abscess, wound infection, colitis, delirium tremens, and hyperbilirubinemia. Discharge occurred 6 to 47 days (median 12 days) postoperatively and was prolonged in patients suffering from a complication. PD is associated with significant morbidity. PG is a safe alternative to pancreaticojejunostomy for managing the pancreatic remnant.

Adenocarcinoma↗
PubMed2001

Age is not a contraindication to pancreaticoduodenectomy.

The incidence of pancreatic cancer has increased threefold over the last 40 years with the greatest rate of growth occurring in the elderly. In the past it was suggested that elderly patients tolerated pancreaticoduodenectomy less well than younger patients with higher mortality rates. This single-institution experience examines the question of whether age is a significant factor in relation to morbidity and mortality in patients undergoing pancreaticoduodenectomy. Between 1994 and 1999 outcomes of 122 patients who underwent pancreaticoduodenectomy were reviewed. There were 48 patients 70 years of age and older and 74 patients less than 70 years of age. Both groups were compared with respect to preoperative clinical prognostic determinates and perioperative factors affecting morbidity and mortality. There was no significant difference between the two groups comparing their comorbidities, use of preoperative antibiotics, intraoperative blood loss, or length of hospital stay (11.9 and 10.8 days respectively). The two groups were also similar with regard to pathologic diagnosis with pancreatic adenocarcinoma being the most frequently encountered neoplasm. There was one death in the less-than-70-year-old group and none in the older group. No significant difference in the rate of complications was appreciated. These data demonstrate that pancreaticoduodenectomy can be performed safely in patients 70 years of age and older with morbidity and mortality rates similar to those of younger individuals.

Adenocarcinoma↗
PubMed2000

The increasing problem of unusual pancreatic tumors.

HYPOTHESIS: Patients presenting with a pancreatic mass often have a curable lesion rather than the more common adenocarcinoma. Greater awareness of this among nonsurgeons is necessary. DESIGN: Retrospective case series. SETTING: Tertiary care referral hospital. PATIENTS: All patients who presented with a pancreatic mass during the 8 years from 1990 to 1998 were studied. Patients with a history of chronic pancreatitis, a functioning pancreatic neuroendocrine tumor, or pancreatic adenocarcinoma were excluded. Forty patients were identified, demographic and clinical characteristics recorded, and long-term follow-up obtained. INTERVENTIONS: Therapy included either a Whipple procedure or distal pancreatectomy. Two patients underwent a biliary bypass. MAIN OUTCOME MEASURES: Tumor histology, morbidity, and survival. RESULTS: Three hundred thirty-six patients with a pancreatic mass were treated during this 8-year period. Two hundred ninety-six of these had pancreatic adenocarcinoma. Forty (11.9%) of the 336 patients had other types of pancreatic tumors. Two thirds of these patients were female, with an average age of 57 years. Seventy-five percent of these tumors were either malignant or potentially malignant. In several instances, cystic tumors were diagnosed as inflammatory pseudocysts and managed accordingly. Fourteen (35%) of 40 patients had no symptoms and their tumor was found on a computed tomographic scan performed for another indication. Percutaneous biopsy was performed in 9 patients, of whom 5 were assigned an incorrect diagnosis. There were no operative deaths, although the postoperative complication rate was 23%. CONCLUSIONS: In this series, nearly 12% of patients presenting with a pancreatic mass did not have pancreatic adenocarcinoma, but rather more favorable lesions amenable to operation. Preoperative biopsy should not be carried out. Curative procedures can be safely performed in centers seeing a large number of patients with pancreatic tumors, and the long-term results of extirpation are excellent.

Adenocarcinoma↗
PubMed2000

Portoenterostomy: an old treatment for a new disease.

HYPOTHESIS: Portoenterostomy may be an effective treatment for patients sustaining a thermal injury to the hepatic duct confluence during laparoscopic cholecystectomy. DESIGN: Case series. SETTING: A tertiary care referral hospital. PATIENTS: A consecutive series of 5 female patients referred and treated between November 13, 1991, and December 17, 1998. Ages ranged from 29 to 65 years. In addition to the ductal injuries at or above the hepatic duct confluence, 3 patients also had a major hepatic vascular injury. The patients were available for follow-up for 7 to 91 months postoperatively. INTERVENTIONS: All patients underwent a portoenterostomy (Kasai procedure) with suturing of a Roux limb to the hepatic tissue surrounding the transected hepatic ducts. Transhepatic stents were inserted either preoperatively or postoperatively for rising liver enzyme levels in 4 patients. MAIN OUTCOME MEASURES: Symptoms and results of liver function tests. RESULTS: Stents remained in place for 9 to 25 months in 4 patients. All 5 patients were symptom free and functioning normally; 3 had normal liver functions; 2 had mildly elevated alkaline phosphatase levels only. CONCLUSION: Portoenterostomy, usually in combination with postoperative stenting, may be an option to consider in life-threatening injuries involving the hepatic duct bifurcation in which standard biliary reconstruction techniques are not feasible.

Acute Disease↗
PubMed2000

Invited critique

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Journal Article↗
PubMed2000

Primary malignant melanoma of the common bile duct: a case report and review of the literature.

Primary malignant melanoma of the common bile duct is rare. To our knowledge, only 6 cases have been reported previously. The pathologic diagnosis of primary malignant melanoma in extracutaneous sites often requires the use of confirmatory immunohistochemical stains and electron microscopy studies, as well as tests to rule out other possible remote or concurrent primary sites. The presence of junctional activity adjacent to the tumor is another important requisite for the diagnosis of this entity. Nevertheless, absolute exclusion of a metastatic melanoma from an unknown occult site or regressed site is not entirely possible. We describe our observations in a case of primary malignant melanoma of the common bile duct in a 48-year-old man and discuss the criteria for diagnosis of primary melanoma.

Adult↗
PubMed1999

The failed gastrointestinal anastomosis: an inevitable catastrophe?

BACKGROUND: There is a great deal of conflicting data regarding risk factors for anastomotic leakage, with most studies being small and looking only at anastomoses performed at one level of the gastrointestinal (GI) tract. Surgeons have looked at patient and technical variables with inconsistent findings. The purpose of this study was to evaluate the incidence, possible predictive factors, and results of treatment of anastomotic dehiscence in patients undergoing operations at all levels of the GI tract. STUDY DESIGN: We evaluated the records of 2,842 patients undergoing esophagogastrectomy, total or partial gastrectomy, enterectomy, and partial or subtotal colectomy over a 12-year period. Complete demographic data, comorbidity, and details regarding anastomotic technique were collected on all patients sustaining leaks along with diagnostic methods used, treatment modalities, and outcomes data. Using age and gender-matched case control methodology, we compared patients sustaining an anastomotic leak to those undergoing successful anastomoses. RESULTS: Fifty-one of 2,842 patients (1.8%), ranging from 1.1% of enterectomy patients to 4.8% of total gastrectomy patients, sustained an anastomotic dehiscence. Foregut procedures were accompanied by a significantly increased rate of leakage, and depending on location, diagnosis was made between the 6th and 9th postoperative day. For each procedure, deaths from factors other than leakage far exceeded deaths from leaks. Standard risk stratifiers did not predict occurrence of leakage. Overall, 24% of patients sustaining a leak died, and this complication necessitated multiple reoperations and significantly increased length of hospital stay. CONCLUSIONS: In view of these findings, standard preoperative strategies to prepare these patients for operation may prove unsuccessful, because minimizing the incidence of anastomotic leaks will have little overall impact on survival. In addition, efforts to accomplish early hospital discharge may prove hazardous, because many of these patients manifest their leaks later in the postoperative period than is generally assumed. Improved management of GI tract disruption, including aggressive attempts at diagnosis, ICU care, antibiotics, and nutritional support may further increase survival in these patients.

Anastomosis, Surgical↗
PubMed1998

Intra-aortic balloon counterpulsation in patients with severe cardiac dysfunction undergoing abdominal operations.

OBJECTIVE: To assess the effectiveness of intra-aortic balloon counterpulsation (IABC) as adjunctive treatment in patients undergoing abdominal operations. DESIGN: Retrospective review of patient medical records to determine the incidence of mortality following abdominal surgery and the incidence of complications from IABC. SETTING: University-based, tertiary care hospital. PATIENTS: Sixty-eight patients who underwent an abdominal operation and IABC during the same hospitalization were divided into the following groups: Group 1, IABC initiated prior to operation to enhance perioperative cardiac function; group 2, IABC used to treat cardiogenic shock in a patient who subsequently required an operation while undergoing IABC; and group 3, IABC device inserted and removed for treatment of cardiogenic shock in a patient who subsequently required an operation within 30 days of removal of the device. MAIN OUTCOME MEASURES: The incidence of mortality in IABC-supported patients and IABC-related complications. RESULTS: In group 1, excluding 3 patients who died following emergency operation, 26 patients underwent nonemergency procedures and had a 12% mortality rate. In group 2, 5 of 6 patients who underwent emergency operations died, whereas 3 of 4 patients who required only urgent operations survived. In group 3, 18 (62%) of 29 patients who underwent urgent or emergent operations died postoperatively. Thirteen patients experienced complications related to IABC; there were no deaths and no limbs were lost to ischemia. CONCLUSIONS: This is the largest reported series looking at the utility of IABC as adjunctive treatment for patients undergoing abdominal operations. The outcome for those patients requiring emergency operations remains poor, but it is likely that more liberal use of IABC in patients with severe cardiac dysfunction who require nonemergency operations may improve patient outcome.

Abdomen↗
PubMed1997

Node-positive duodenal carcinoma is curable.

OBJECTIVES: To document our experience with duodenal carcinoma during the past 15 years to ascertain optimal treatment. DESIGN: A retrospective case series. SETTING: A tertiary care referral center. PATIENTS: A consecutive sample of 24 patients, 17 men and 7 women, with duodenal carcinoma was evaluated during the 15 years ending in December 1992. Ages ranged from 44 to 81 years. All patients were available for follow-up for a minimum of 20 months. INTERVENTIONS: Therapy included 15 radical pancreaticoduodenectomies (Whipple procedures), 7 bypass operations, and 2 segmental resections. MAIN OUTCOME MEASURES: Tumor staging and survival. RESULTS: Segmental resections were performed in 2 patients, bypass operations in 7, and Whipple procedures in 15. One patient in each of the bypass and Whipple groups died postoperatively. All other patients who underwent bypass and segmental resection died of cancer. Of 14 patients surviving a Whipple procedure, 9 continue to survive with an average follow-up of 77 months. Four of these patients had lymph nodes involved with cancer and have survived for longer than 5 years. CONCLUSIONS: Adenocarcinoma of the duodenum gives rise to nonspecific gastrointestinal tract symptoms, and diagnosis is often delayed. Despite this delay, the Whipple procedure may still be curative for patients with positive lymph nodes, a fact poorly appreciated in the surgical literature. The role of segmental resection for distal duodenal tumors is unclear.

Adenocarcinoma↗
PubMed1997

Abdominal operations in patients with cirrhosis: still a major surgical challenge.

BACKGROUND: Hepatic transplantation and portasystemic shunts can be safely performed in patients with advanced liver disease, whereas other abdominal procedures appear to have a much higher mortality rate. This study reviews the outcomes of patients with cirrhosis after the full spectrum of abdominal operations. METHODS: In a 12-year period, 92 patients diagnosed with cirrhosis required either an emergent or elective abdominal operation. There were four categories of operations: cholecystectomy in 17 patients, hernia in 9, gastrointestinal tract in 54, and other procedures in 12. Fifty-five clinical, laboratory, and operative variables were analyzed to identify factors predictive of poor outcome. RESULTS: Coagulopathy developed in 24 patients (27%) and sepsis in 15 (16%). The mortality rate after emergent operations was 50%, compared to 18% for elective cases (p = 0.001). Other factors that predicted mortality included the presence of ascites (p = 0.006), encephalopathy (p = 0.002), and elevated prothrombin time (p = 0.021). The mortality in Child's class A patients was 10%, compared to 30% in class B and 82% in class C patients. CONCLUSIONS: Patients with cirrhosis undergoing elective or emergent operations are at a significant risk of developing postoperative complications leading to death. The most accurate predictor of outcome is the patient's preoperative Child's class.

Abdomen, Acute↗
PubMed1994

Parapubic hernia following radical retropubic prostatectomy.

We report a parapubic hernia in a 54-year-old patient following radical retropubic prostatectomy. This complication can occur when the musculotendinous insertions of the rectus abdominis muscle are divided from the pubis. Bowel contents herniate over the pubic crest and can be misdiagnosed as an incisional or inguinal hernia. Successful repair depends on closure of the entire defect. Elective repair necessitates the use of prosthetic mesh.

Hernia, Ventral↗
PubMed1994

The rationale for surgical treatment of mesenteric and retroperitoneal cysts.

Mesenteric and retroperitoneal cysts are rare, usually asymptomatic lesions. Because of this, several recommendations in the literature caution against operative therapy in the absence of symptoms. During a recent 10 year period, six patients presented to our hospital with symptomatic mesenteric or retroperitoneal cysts; two of these patients were septic and had infection within the cyst. All six patients underwent excision with complete resolution of symptoms and no morbidity. With the advent of frequent abdominal CT scanning for a variety of reasons, it is likely that more of these lesions will be noted in the future. In view of the potential for development of symptoms and complications, we feel that any good risk patient found to harbor such a cyst should undergo complete excision.

Aged↗
PubMed1993

Nonductal tumors of the pancreas. The importance of laparotomy.

OBJECTIVES: To delineate the incidence of nonductal pancreatic neoplasms and determine whether distinguishing clinical or radiologic characteristics exist. METHODS: From 1977 through 1990, we examined 353 patients with a pancreatic mass as demonstrated on abdominal computed tomography or ultrasonography. Patients with chronic pancreatitis or functioning neuroendocrine tumors were excluded. All patients underwent operative exploration for histopathologic diagnosis and resection when possible. RESULTS: Adenocarcinoma of the pancreas was seen in 322 patients. The remaining 31 patients (8.8%) were found to have nonductal tumors of the pancreas, including nonfunctioning islet cell tumors (15), cystadenoma (nine), lymphoma (five), lipoma (one), and mesothelioma (one). These neoplasms were evenly distributed between the head and tail of the pancreas, while most of the ductal pancreatic carcinomas were located in the pancreatic head. While abdominal computed tomography and ultrasonography accurately identified most cystic neoplasms, the remaining nonductal lesions were indistinguishable from ductal pancreatic tumors. Preoperative biochemical studies and liver function tests failed to separate ductal and nonductal pancreatic masses. Average survival for patients with nonductal lesions was significantly longer compared with ductal tumors of the pancreas. CONCLUSIONS: Because increasing reliance on advanced radiologic and invasive nonoperative diagnostic testing may deny proper surgical therapy to patients with nonductal neoplasms of the pancreas, laparotomy and histopathologic diagnosis are advisable in most patients with an isolated pancreatic mass.

Adenocarcinoma↗
PubMed1993

Free splenic artery used in aortocoronary bypass.

Many alternative bypass conduits for coronary revascularization have been used since the introduction of the saphenous vein. The internal mammary artery has demonstrated superior long-term patency rates compared with vein grafts. Other arterial grafts previously investigated include the right gastroepiploic artery, inferior epigastric artery, radial artery, and splenic artery. This case reports bypass using a free splenic artery and a pedicled right gastroepiploic artery, each with successful postoperative patency.

Aged↗