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K M Brady

Publications and source records attributed to K M Brady.

13 recordsLinked to original sources
PubMed2005

Laparoscopic vs open total colectomy: a case-matched comparative study.

BACKGROUND: Open total colectomy and ileorectal anastomosis (OTC) is a major colorectal procedure which would preclude laparoscopy in many centers because of technical difficulty and the fact that laparoscopic total colectomy (LTC) takes much longer than standard laparoscopic proctosigmoidectomy (LPS). This study compares OTC with LTC and LPS. METHODS: In this study, 34 LTC patients (May 1999 to August 2003) were matched for age, diagnosis, operative period, and procedure with patients undergoing OTC. Patients with a previous major laparotomy were excluded from the open group. Groups were compared for gender, American Society of Anesthesiology (ASA) classification, operating time, estimated blood loss, length of hospital stay (LOS), complications including readmissions, and costs. The LPS cases were picked randomly from the laparoscopic database (every eighth patient), and the OT and LOS were noted. RESULTS: The LTC and OTC groups were matched for age (mean, 31 vs 34 years; p = 0.2), sex (14 vs 13 females; p = 0.8), ASA (8/23/3/0 vs 8/22/4/0, class 1/2/3/4). The body mass index was higher in the open group (23.8 vs 27.9; p = 0.04). The operating time was significantly longer (187 vs 126 min; p = 0.0001) and the median LOS shorter in the LTC group (3 days [IQR, 2.5-5 days] vs 6 days [IQR 4-8 days]; p = 0.0001). The estimated blood loss was significantly less in the LTC group (168 [50-700] ml) vs 238 [50-800] ml); p = 0.001, but there was no significant difference in the complication (26.5% vs 38.2%; p = 0.4) readmission (11.8% vs 14.7%; p = 1.0), reoperative rates (8.8% vs 11.8%; p = 1.0), or direct costs ($4,578 vs $4,562; p = 0.3). One LTC patient died expired on postoperative day 2 of a cardiac event. Four patients (11.8%) required conversion for obesity (n = 2), adhesions (n = 1), or intraoperative hemorrhage (n = 1). The operating times were 36 min longer in the LTC group than in the LPS group (151 vs 187 min; p = 0.02), but there was no significant difference in the LOS. (3 vs 3 days, p = 0.2). CONCLUSIONS: The findings show that LTC provides a significant decrease in the LOS over OTC, with increased operating time, but without any change in other parameters. A laparoscopic approach to subtotal colectomy is recommended for suitable patients when an experienced team is available.

Adult↗
PubMed2004

Elective laparoscopic surgery for benign internal enteric fistulas: a review of 43 cases.

BACKGROUND: Laparoscopic surgery has been applied to the management of various colorectal conditions, with shorter recovery periods than reported for open surgery. This study reviewed the feasibility and outcome of laparoscopic surgery for benign internal enteric fistulas. METHODS: All the patients undergoing laparoscopic surgery for colovesical, colovaginal, enterovesical, and enterocolic fistulas caused by diverticulitis or Crohn's disease from 1995 to 2003 were identified from the prospective laparoscopic surgery database and retrospectively analyzed. Crohn's ileo-ileal fistulas were excluded from the study because these are generally resected more simply en bloc with the terminal ileum. RESULTS: This study enrolled 43 patients (23 men and 20 women) with median age of 43 years, a mean body mass index of 24.5, and in American Society of Anesthesiology (ASA) distribution of 3/33/8/0 (class 1/2/3/4). The diagnosis was diverticular for 24 patients and Crohn's disease for 19 patients. The mean operative time was 163 +/- 80 min (155 in completed and 180 in converted cases), and the mean length of hospital stay was 5.2 +/- 4.7 days (3.9 in completed and 7.9 days in converted cases). A total of 14 patients (32.6%) required conversion for dense adhesions (n = 8), duodenal involvement (n = 3), multiple fistulae (n = 1), fecal leak (n = 1), and additional pathology (n = 1). Conversion rates, analyzed by fistula type, were duodenal (100%), vaginal (66.7%), sigmoid (27.7%), bladder (15.4%), enterocolic (0%), and colocolic (0%). There were six major complications (14%) including anastomotic leak (n = 3), abscesses (n = 2), and postoperative bleeding (n = 1). There were seven minor complications (16.3%) including postoperative ileus (n = 2), transient pleural effusion (n = 1), wound infection (n = 1), transient small bowel obstruction (n = 2), and brachial plexus neuralgia (n = 1). There was no significant difference in the complication (p = 0.57), reoperation (p = 0.3), or readmission (p = 0.4) rates between the completed and converted cases. CONCLUSIONS: Laparoscopic surgery for benign internal enteric fistula offers the earlier recovery seen with other laparoscopic colorectal operations. Duodenal and vaginal involvement by the fistula is associated with a higher conversion rate. A low threshold toward early conversion is useful in these difficult cases to reduce delays in the operating room and the unnecessary use of hospital resources.

Adult↗
PubMed2003

Evaluation of POSSUM and P-POSSUM scoring systems in assessing outcome after laparoscopic colectomy.

BACKGROUND: The purpose of this study was to compare the actual and predicted risk-adjusted morbidity and mortality after laparoscopic colectomy (LAC) calculated using both the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and Portsmouth POSSUM (P-POSSUM) scoring systems. METHODS: All patients who underwent LAC performed by a single surgeon between March 1999 and December 2000 were analysed. The observed morbidity and mortality rates were compared with those predicted by the POSSUM scoring system, and the observed mortality rate with that predicted by P-POSSUM. The operative severity component of the operative score was sequentially decreased from 4 (standard score for open colectomy) to 2, then 1, in an attempt to correct overprediction. RESULTS: Two hundred and fifty-one consecutive patients underwent LAC, with a conversion rate of 8.0 per cent. The morbidity rate (6.8 per cent) was significantly lower than the predicted rates calculated with an operative score of 4 or 2 (12.4 per cent, P < 0.001; 9.6 per cent, P = 0.001), but was fully corrected with an operative score of 1 (7.0 per cent, P = 0.325). The observed mortality rate (0.8 per cent) was significantly different from the expected mortality rates calculated using either uncorrected POSSUM (9.6 per cent, P = 0.001) or P-POSSUM (3.5 per cent, P = 0.001). POSSUM (2.6 per cent, P = 0.007) continued to overpredict mortality but P-POSSUM (1.0 per cent, P = 0.001) accurately predicted mortality with an operative score of 1. CONCLUSION: LAC appeared to be associated with lower morbidity and mortality rates than those predicted by the POSSUM scoring system, and with a lower mortality rate than that predicted using the P-POSSUM system.

Adolescent↗
PubMed2002

Clinically based management of rectal prolapse.

BACKGROUND: Laparoscopic repair of rectal prolapse offers the potential of lower recurrence rates for transabdominal repair coupled with the advantages of minimally invasive colorectal surgery. There have been no direct comparisons of the laparoscopic Wells procedure (LWP) and laparoscopic resection with rectopexy (LRR). This study is the first to make a direct comparison of outcomes from laparoscopic LRR and LWP repairs using a selected, symptom-based choice of operative procedure. METHODS: Consecutive patients presenting with complete rectal prolapse were evaluated by clinical history of the degree of constipation, diarrhea, or incontinence. Patients with a history of constipation or normal bowel habits with normal continence underwent LRR, whereas those with diarrhea or anal incontinence underwent LWP. The collected data included age, gender, operative time, length of hospital stay (LOS), operative blood loss, complications, and postoperative symptoms of constipation or diarrhea. Continence was scored using the Cleveland Clinic scoring system. RESULTS: Of the 24 patients, 11 underwent LRR and 13 had LWP. The patients in both groups were predominantly, female (LRR, 9/1; LWP, 10/2). The LRR patients were significantly younger (48.6 vs 63.9 years p <0.001). Both operative time and LOS were significantly longer in the RR group (operative time, 128.5 +/- 80.6 min vs 69.9 +/- 13.4 min; LOS, 3.6 +/- 3.1 days vs 2.2 +/- 1.03 days). All patients in the LRR group had constipation preoperative, and no patients were incontinent clinically. Preoperatively, 7 of the 13 patients in the LWP group had preoperative diarrhea, and 1 patient had clinical constipation. A five patients experienced clinical symptoms of fecal incontinence, manifested in different degrees. Postoperative complications occurred only in the LRR group (1 case of abdominal wall hematoma and 2 cases of prolonged ileus). During a mean follow-up period of 18.1 months, there were no recurrences; 10 of the 11 LRR patients had correction of constipation; and 4 of 5 of the incontinent LWP patients had improvement in their symptoms. Constipation developed in one LWP patient. CONCLUSIONS: Clinical assessment of preoperative bowel function and continence allows accurate selection of the appropriate laparoscopic technique for repair of rectal prolapse without the added expense of anal physiologic testing. Although LRR may be associated greater morbidity than LWP, both procedures offer good functional outcome, with short LOS and low recurrence rates.

Adult↗
PubMed1999

Optic neuritis in children: clinical features and visual outcome.

BACKGROUND: The purpose of this paper is to study the clinical spectrum of pediatric optic neuritis. We evaluated the presenting features, neuroimaging findings, cerebrospinal fluid abnormalities, associated systemic disease, and visual outcome in patients with this condition. METHODS: A retrospective analysis was performed on all patients who came to Baylor College of Medicine with optic neuritis during a 6-year period from 1991 to 1997. The degree of initial visual loss, subsequent visual recovery, and associated disease were reviewed. Magnetic resonance images and cerebrospinal fluid findings were also analyzed. RESULTS: Twenty-five patients (39 eyes) 21 months of age to 18 years of age were included in the study, with a mean follow-up of 11 months. Fourteen patients (56%) had bilateral optic neuritis, and 11 patients (44%) had unilateral disease. Thirty-three of 39 eyes (84%) had visual acuity of 20/200 or less at presentation. Twenty-one of 25 patients (84%) were given intravenous methylprednisolone (10 to 30 mg/kg/day). Thirty of 39 eyes (76%) recovered 20/40 visual acuity or better. Three of 39 eyes (7%) recovered vision in the 20/50 to 20/100 range. Six of 39 eyes (15%) recovered vision of 20/200 or less. Twenty-three of 25 patients (92%) underwent magnetic resonance imaging of the brain. A normal magnetic resonance image of the brain was associated with recovery of 20/40 or better visual acuity in 6 of 6 affected eyes (100%). Seven patients were 6 years of age or younger at presentation. Six of 7 (85%) had bilateral disease, and 12 of 13 (92%) affected eyes recovered 20/40 visual acuity or better. Eighteen patients were 7 years of age or older at presentation. Eight of 18 (44%) had bilateral disease, and 10 of 18 patients (56%) had unilateral disease. Eighteen of 26 affected eyes (50%) recovered 20/40 visual acuity or better. CONCLUSION: Pediatric optic neuritis is usually associated with visual recovery; however, a significant number (22%) remain visually disabled. A normal magnetic resonance image of the brain may be associated with a better outcome. Younger patients are more likely to have bilateral disease and a better visual prognosis.

Adolescent↗
PubMed1999

Penetrating cardiac trauma at an urban trauma center: a 22-year perspective.

This is a report of a 22-year experience with penetrating cardiac trauma at a single urban Level I trauma center. We conducted a retrospective chart review supplemented by computerized patient log. Comparisons of mortality between Period 1 (1975-1985; 113 patients) and Period 2 (1986-1996; 79 patients) were by chi2 or Fisher's exact tests. Statistical significance was defined as P < or = 0.05. From 1975 to 1996, 192 patients (mean age, 32 years; 88% male) with penetrating cardiac stab wounds (68%) or gunshot wounds (32%) were treated. The most common initial clinical presentation was cardiac tamponade, and most patients (54%) were hypotensive (systolic blood pressure 30-90 mm Hg). The most common initial intervention in the emergency center was tube thoracostomy. The use of pericardiocentesis as a diagnostic and therapeutic modality in the emergency center virtually disappeared in Period 2, as compared with Period 1. Since 1994, surgeon-performed cardiac ultrasound has been performed and has correctly diagnosed hemopericardium in 12 patients (100% survival). The overall mortality for all patients during the 22-year study interval was 25 per cent and was not significantly different between Period 1 (27%) and Period 2 (22%). The mortality associated with gunshot wounds was increased compared with that of stab wounds. Similarly, mortality for patients who arrested in the emergency center was increased compared with those patients who did not arrest. We conclude: 1) cardiac tamponade is the most common presentation in patients with cardiac wounds; 2) pericardiocentesis in the emergency center has essentially disappeared; 3) surgeon-performed ultrasound of the pericardium should improve survival of future patients who are normotensive or mildly hypotensive; 4) over the last 11 years, there has been a substantial decrease in mortality in patients with stab wounds and a statistically significant decrease in arrested patients; and 5) overall mortality for penetrating cardiac trauma has not changed during the 22-year interval.

Adolescent↗
PubMed1998

Evaluation of treatment modalities for thoracic empyema: a cost-effectiveness analysis.

BACKGROUND: Empyema thoracis is treated with a multitude of therapeutic options. Optimal therapy and cost-containment requires selection of the most appropriate initial intervention. METHODS: A retrospective review of treatment modalities was performed on 77 patients diagnosed with empyema thoracis from 1990 to 1997 at one institution. Mean age was 59 years (range, 21 to 90 years); 52 were men and 25 were women. RESULTS: Sixty-five percent (50/77) were parapneumonic and 68% (52/77) were multiloculated. Treatment modalities were as follows: group 1, antibiotics only (n = 4); group 2, primary intervention: image-directed catheter (n = 20) or tube thoracostomy (n = 24); and group 3, secondary intervention: decortication (n = 17), rib resection or muscle interposition (n = 12). Thirty-four percent (9/20 image-directed catheter and 8/24 tube thoracostomy) had failure of initial intervention. Patients undergoing decortication more often had multiloculated empyema thoracis (16 of 17) compared with those undergoing image-directed catheters (8 of 20) or tube thoracotomy (16 of 24). Length of stay was reduced for decortication patients (17 days) compared with those having image-directed catheters (21.8 days), failed image-directed catheters (29.7 days), or tube thoracostomies (19.6 days). Hospital charges per patient between decortication and image-directed catheter ($34,770.79 versus $37,869.41) were comparable, but charges were significantly decreased in decortication patients as compared with failed image-directed catheters ($55,609.32; p < 0.05). CONCLUSIONS: Our series revealed that early decortication has charges similar to those of primary intervention (image-directed catheter or tube thoracostomy) but is more cost-effective than failed image-directed catheter. We advocate the use of early surgical intervention as the most optimal and cost-effective initial modality for the treatment of empyema thoracis.

Anti-Bacterial Agents↗
PubMed1998

Surgery of the eyelids.

This article reviews the most common pediatric oculoplastic conditions and addresses clinical evaluation as well as medical and surgical management. The complex issues of amblyopia and special considerations for eyelid surgery in children are discussed. A step-by-step approach is used in the treatment of many common pediatric oculoplastic conditions, including congenital blepharoptosis and lid margin defects. Surgical options are explored and clinical examples are provided.

Amblyopia↗
PubMed1997

Glaucoma after cataract extraction and posterior chamber lens implantation in children.

PURPOSE: To evaluate the incidence of postoperative glaucoma in children who have cataract extraction and posterior chamber intraocular lens (IOL) implantation. SETTING: Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA. METHODS: The incidence of glaucoma of all etiologies was evaluated in 45 eyes of 37 selected consecutive patients aged 1 to 18 years who had cataract extraction and posterior chamber IOL implantation from 1991 to 1994. Mean follow-up was 23 months (range 6 to 38 months). Nineteen patients had traumatic and 18 had developmental cataract. Exclusion criteria were microcornea smaller than 9.0 mm in diameter, preoperative glaucoma, or poor pupil dilation. The surgical technique comprised a continuous curvilinear anterior capsulorhexis in most cases, extracapsular aspiration by Ocutome or phacoemulsification, and retention of the posterior capsule. A peripheral iridectomy was done in 7 eyes (16%). Postoperative medications included topical atropine combined with topical, subconjunctival, and systemic corticosteroids and antibiotics. RESULTS: Three patients with traumatic cataract developed postoperative glaucoma during the follow-up. One developed pseudophakic pupillary block; however, a peripheral iridectomy prevented glaucoma. Two other patients developed late-onset glaucoma: one secondary to angle recession and the other to peripheral anterior synechias. No patient with developmental cataract developed glaucoma. CONCLUSION: Careful patient selection, atraumatic surgical technique, continuous curvilinear capsulorhexis, in-the-bag IOL placement, postoperative atropine, and topical and systemic corticosteroids significantly lower the incidence of pseudophakic pupillary block and glaucoma. Although no patient developed glaucoma, lifelong follow-up is mandatory to detect chronic open-angle and traumatic angle-recession glaucoma.

Adolescent↗
PubMed1995

Cataract surgery and intraocular lens implantation in children.

PURPOSE: To evaluate visual outcome and complications after extracapsular cataract extraction with posterior chamber intraocular lens implantation in children. METHODS: Extracapsular cataract extraction with posterior chamber intraocular lens implantation was performed on 20 eyes of 19 patients with traumatic cataract, ten eyes with unilateral congenital or developmental cataract, and 15 eyes (eight patients) with bilateral developmental cataract. Nd:YAG posterior capsulotomy was performed in the early postoperative period as indicated. RESULTS: Fourteen (70%) of 20 eyes with traumatic cataract had best-corrected pseudophakic visual acuity of 20/40 or better. When we excluded four eyes with macular injuries from analysis, 14 (87%) of 16 eyes had visual acuity of 20/40 or better. In patients with bilateral cataract in whom vision was quantified by Snellen acuity (nine eyes of five patients), nine of nine eyes had best-corrected pseudophakic visual acuity of 20/40 or better. In the remaining three patients, six of six eyes had central steady and maintained fixation. Visual outcome was poorest in patients with unilateral cataract (ten eyes); one eye had best-corrected pseudophakic visual acuity of 20/40; two eyes, 20/60; two eyes, 20/70; one eye, 20/100; and two eyes, 20/200. One additional eye had central steady maintained fixation and noncentral fixation. Five of ten eyes had four or more lines improvement in visual acuity. Postoperative complications occurred in five eyes, each of which had traumatic cataract. Three eyes developed iris capture, one eye had a postoperative intraocular hemorrhage, and another developed a dense secondary membrane. In 45 postoperative postoperative eyes, 27 (60%) received one Nd:YAG laser posterior capsulotomy. A second Nd:YAG laser posterior capsulotomy was performed in 11 (41%) of these 27 eyes. CONCLUSIONS: Extracapsular cataract extraction with posterior chamber intraocular lens implantation in children can be accomplished in selected patients, with generally favorable results. However, many of the patients in this series remain potentially amblyogenic, and long-term follow-up may temper our present visual results.

Adolescent↗