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Biomedical subjects

K W Sharp

Publications and source records attributed to K W Sharp.

35 records · Page 2Linked to original sources
PubMed1990

Changes in gallbladder volume do not affect cystic duct resistance.

To our knowledge, the relationship between gallbladder volume and cystic duct function has not been studied. We hypothesized that changes in gallbladder volume would influence cystic duct resistance. The effect of gallbladder volume changes on cystic duct resistance to both prograde (emptying) and retrograde (filling) steady-state flow was tested in 12 dogs under basal cholecystokinin-stimulated conditions utilizing a multiport catheter with a highly compliant balloon placed within the gallbladder fundus. Gallbladder volume was regulated by varying balloon volume from empty to just beyond physiologic distention. Cystic duct resistance was not affected by balloon volume under basal or stimulated conditions or by the direction of perfusate flow. This study demonstrated no relationship between gallbladder volume and cystic duct resistance and did not demonstrate a cystic duct sphincter mechanism at physiologic gallbladder volumes.

Animals↗
PubMed1990

Diverticular disease of the jejunum and its complications.

Jejunal diverticulosis is an uncommon, acquired condition that has been encountered recently in four patients. These cases (two patients with diverticulitis, one patient with chronic abdominal pain, and one patient incidentally discovered at laparotomy for colonic diverticulitis) are reported. Acute complications of jejunal diverticulosis include diverticulitis, bleeding, and intestinal obstruction. Chronic complications include intractable abdominal pain, malabsorption, and intestinal pseudo-obstruction. Up to 15 per cent of patients with jejunal diverticulosis may require small-bowel resection for treatment of these acute or chronic complications. The clinical significance, proper diagnostic evaluation, and treatment of jejunal diverticular disease are reviewed.

Abdominal Pain↗
PubMed1990

Local resection of tumors of the ampulla of Vater.

Local resection of an ampullary tumor with reimplantation of the pancreatic and bile ducts was first described by William S. Halsted in 1899. Technical hazard and unsuitability in malignant ampullary tumors have unfortunately led to a disregard for this operation that is unwarranted. Radical pancreaticoduodenectomy is now the most common method of resecting benign and malignant ampullary tumors. Experience was gained with two high-risk patients with benign adenomatous polyps obstructing the ampulla of Vater. Their medical unsuitability for radical pancreaticoduodenectomy led us to revive the procedure of wide local excision of these tumors with reimplantation of the pancreatic and bile ducts. Operative time and blood loss were substantially less than radical resection and postoperative recoveries were relatively uncomplicated. Radical resection of benign ampullary tumors may be appropriate for good-risk patients in whom the risk of local recurrence outweighs the operative risk. We suggest that local resection of benign ampullary tumors is the procedure of choice in high-risk patients and that it be considered in palliation of limited local malignancies of the ampulla in high-risk patients.

Adenocarcinoma, Papillary↗
PubMed1989

Common bile duct healing. Do different absorbable sutures affect stricture formation and tensile strength?

Few basic investigations have addressed the problem of common bile duct strictures. We systematically investigated the healing canine end-to-end choledochal anastomosis and tested the hypothesis that common bile duct anastomoses sutured with monofilament polyglyconate absorbable suture would heal with less stricture formation and greater tensile strength than those sutured with braided polyglactin 910 and chromic catgut sutures. Seventy-six canines, randomized to control vs sutured groups, underwent either mobilization (controls) or transection of the mid-common bile duct and were allowed to heal 5, 10, 15, or 50 days postoperatively before sacrifice. The type of absorbable suture used to construct a common bile duct anastomosis was found to have no major effect on anastomotic strictures nor on anastomotic breaking strength. Polyglyconate suture caused significantly less perianastomotic inflammation than did chromic suture, with polyglactin 910 sutures evoking an intermediate inflammatory response. Surgeons may safely choose sutures for biliary procedures based on the clinical circumstances and personal preference.

Anastomosis, Surgical↗
PubMed1989

Tumor seeding from percutaneous biliary catheters.

Percutaneous transhepatic biliary decompression has been used since 1973 as a preoperative surgical adjunct in patients with obstructive jaundice. Tumor seeding along the catheter tract is an unusual complication but it occurred recently in one of our patients who had preoperative biliary drainage for four days. Four months after his pancreaticoduodenectomy, a 2-cm nodule developed at the catheter exit site. This nodule was a metastatic focus of adenocarcinoma similar to his pancreatic tumor. He died 1 month later and at autopsy was found to have numerous metastases along the catheter tract. A review of the world literature found 17 other patients with this complication. Thirteen of the 18 total patients had catheters placed for palliation, while 5 patients underwent preoperative drainage before definitive procedures, and 4 of these patients had undergone "curative" resections. Nine of the 18 patients had biliary obstruction from cholangiocarcinoma, while seven patients had primary pancreatic carcinoma. Positioning of the catheter tip above the obstructing tumor and maintaining the catheter for only a short duration before operation (mean 8 days for resected patients, range 2 to 16 days) did not protect against catheter-related tumor seeding. Patients with suspected malignant obstruction of the biliary tract who may have resectable tumors should not undergo routine preoperative biliary decompression. If, on exploration, the tumor is found to be unresectable, then a palliative bypass may be performed.

Adenocarcinoma↗
PubMed1989

Recent experience with benign biliary strictures.

The management of benign biliary strictures continues to represent one of the most difficult problems in the practice of general surgery. Twenty-eight consecutive patients with benign strictures treated between 1972 and 1987 are reviewed in this report. Stricture etiology was iatrogenic in 13 patients, pancreatitic in 11, idiopathic in three, and traumatic in one. The authors performed 27 operations and three percutaneous transhepatic balloon dilatations in the treatment of these patients. Operative morbidity was 18 per cent; there were no operative deaths. Treatment was successful in 23 of 28 patients with a mean followup of four years, and four of the five patients with initially unsuccessful results have undergone successful remedial operations. Roux-en-Y biliary enteric diversion procedures have been most successful in these patients: seven patients with Roux-en-Y choledochojejunostomy without recurrence (mean followup of 62 months) and eight patients with Roux-en-Y hepaticojejunostomy with a success rate of 87.5 per cent (mean followup of 50 months). Two patients underwent three percutaneous transhepatic balloon dilatations; one has had a good result with short followup and the other failed on two occasions and has required a remedial operation. Benign biliary strictures have multiple etiologies. Therapeutic approaches, which now include nonoperative procedures, must be tailored to the needs of individual patients. The potential for recurrence is always present. Longterm followup remains essential in the management of patients with this disorder.

Adult↗
PubMed1989

Pancreatoduodenectomy with pyloric preservation for carcinoma of the pancreas: a cautionary note.

Radical pancreatoduodenectomy for treatment of pancreatic carcinoma has been the surgical standard of care for the past four decades. The recent popularization of pylorus-sparing pancreatoduodenectomy to treat benign pancreatic disease, because of its decreased morbidity and long-term nutritional consequences, has led to the use of this procedure in cases of pancreatic carcinoma. We report recent experience with three patients with pancreatic carcinoma in whom pyloric preservation would have compromised the potential chance for curative resection or compromised palliation because of occult spread of tumor to a region not resected with this new operative approach. Two patients had proximal, microscopic intramural spread of pancreatic adenocarcinoma within the duodenum or antrum--a mode of spread not previously reported with pancreatic carcinoma. Both patients had no other evidence of metastatic involvement, and both would have had positive surgical margins in a pylorus-sparing pancreatoduodenectomy. A third case demonstrates a true submucosal recurrence of pancreatic carcinoma after a pylorus-sparing pancreatoduodenectomy. It is debatable that any case demonstrating intramural spread within the duodenum could be cured with a standard Whipple resection as this may well represent another sign of incurability, like lymphatic or perineural spread, but it is clearly a major potential obstacle to palliation if submucosal recurrences occur as a result of the use of the pylorus-sparing pancreatoduodenectomy in cases of pancreatic cancer. The use of pylorus-sparing pancreatoduodenectomy in resectable pancreatic cancers must be viewed skeptically at this time.

Adenocarcinoma↗
PubMed1988

Acute cholecystitis.

Acute cholecystitis is a common cause of the acute abdomen. The diagnosis has been distinctly improved with the development of ultrasonography and hepatobiliary scanning over the past 20 years. The treatment is cholecystectomy, with early as opposed to delayed operation gaining increasing popularity nationwide. Acute acalculous cholecystitis and emphysematous cholecystitis are special features of acute cholecystitis occurring in more complicated cases and requiring diligence in diagnosis and great care in treatment.

Abdomen, Acute↗
PubMed1988

Is total pelvic exenteration reasonable primary treatment for rectal carcinoma?

Total pelvic exeneration (TPE) is reasonable primary surgical therapy in select patients with large bulky locally invasive rectal cancers that can be removed en bloc. Many do not have either nodal or distant metastasis. Furthermore, TPE can be curative and often is palliative for similar lesions that are recurrent or nonresponsive to radiation therapy. Operative mortality rates should be under 10% and can be under 5% for primary cases. Although improvement in preoperative management and operative technique, especially with urinary conduits and postoperative care is clear, both early and late complications are significant. Unfortunately, preoperative identification of those patients requiring TPE rather than abdominoperineal or low anterior resection remains poor. Furthermore, recent improvements in techniques for pelvic slings to prevent small bowel entrapment and protection from irradiation or myocutaneous flaps to obliterate the massive dead space are not yet clearly established as preventors of either early or later complications.

Carcinoma↗
PubMed1988

Do multi-lumen catheters increase central venous catheter sepsis compared to single-lumen catheters?

Triple-lumen catheters (TLC) are now routinely used in critically ill and multiply injured patients who require multi-port central venous access. An apparent rise in catheter contamination and catheter-related sepsis (CRS) occurred in patients receiving total parenteral nutrition (TPN) through a TLC as opposed to a single-lumen catheter (SLC). A prospective study was performed to determine rates of catheter contamination and CRS in multiple trauma and general surgical-medical patients who received TPN through TLC's and SLC's. Three hundred seven TLC's and 68 SLC's were placed in 234 patients during a 12-month period. There was no statistically significant difference in the rate of contamination or CRS between the two groups although there was a trend toward increased CRS and contamination in the TLC group. TLC's may be used for short-term administration of TPN without significant increase in catheter contamination or CRS.

Bacterial Infections↗
PubMed1988

Efficacy of computerized tomography in the preoperative staging of pancreatic carcinoma.

The increasing use of nonoperative methods for the diagnosis and palliative treatment of pancreatic cancer has placed greater emphasis on computerized tomography (CT) in staging of this malignancy. The present study was done to review our experience with CT in staging pancreatic cancer, specifically its efficacy in predicting lesions amenable to curative versus noncurative surgical treatment. Sixty six consecutive patients with pancreatic cancer who were considered potential candidates for surgical resection and who had preoperative CT scans over the 4-year period from 1982 through 1986 were studied. Preoperative CT scans were reviewed by a radiologist without knowledge of patients' surgical management. CT criteria for unresectable disease include hepatic and distant metastasis as well as evidence of locally advanced disease, including peripancreatic fascial extension, extension of tumor to locally contiguous structures, vascular encasement/invasion, and local lymphadenopathy. CT predicted resectability with a sensitivity of 75 per cent and a positive predictive value of 38 per cent. Unresectability was predicted with a sensitivity of 72 per cent and positive predictive value of 93 per cent. CT incorrectly predicted unresectable disease in three patients who had a curative resection. CT was most reliable when it predicted unresectability due to the presence of hepatic and/or distant metastasis. CT predicted unresectability with least sensitivity using criteria for locally advanced disease. Therapeutic decisions for nonoperative management of patients with pancreatic cancer based upon CT predictions of unresectable disease, especially predictions of unresectability solely on the basis of locally advanced disease, can not be recommended at this time.

Adenocarcinoma↗
PubMed1985

Transhiatal (blunt) esophagectomy for malignant and benign esophageal disease: clinical experience and technique.

"Blunt" transhiatal esophagectomy was performed in 23 selected patients. Nineteen had squamous carcinoma of the esophagus (upper third, 1; middle third, 12; distal third, 6), and 2 had adenocarcinoma of the distal esophagus. The other 2 patients had severe lye strictures. Resection with reconstruction was performed in one stage. Esophagogastric continuity was restored using the stomach in the posterior mediastinal position in 20 patients and in the substernal position in 2. The colon in the posterior mediastinal position was used in 1 patient with a lye stricture. Transmural tumor extension or cervical or celiac nodal metastases or both were present in 18 of 21 patients with carcinoma. There was 1 hospital death due to pericardial tamponade. Morbidity included a transient cervical anastomotic leak in 3 patients, one temporary and three permanent unilateral recurrent laryngeal nerve palsies, one intraoperative splenic injury, and severe hemorrhage requiring sternotomy for control in 1 patient. Pulmonary complications occurred in 4 patients: aspiration pneumonia (1) and moderate atelectasis (3). Three patients have died (11, 12, and 17 months postoperatively) in the group with cancer, with follow-up time of 3 to 30 months (mean, 15 months). Transhiatal blunt esophagectomy is a safe and effective procedure in many patients with either esophageal cancer or extensive, benign esophageal strictures.

Adenocarcinoma↗
PubMed1984

Toxic effects of intrahepatic reflux of monooctanoin in a canine model.

Monooctanoin (MO), when infused into the common bile duct (CBD), is an effective agent in dissolving retained CBD stones. If the stone migrates and obstructs the distal CBD, the solution could be infused under pressure resulting in intrahepatic reflux. The relationship between the infusion pressure and the safety of monooctanoin has not been evaluated. To study the effects of intrahepatic reflux of MO, a canine model was used and solutions were infused into an obstructed CBD under controlled pressure. Solutions of normal saline (NS), 150 mM sodium cholate (Ch), or MO were infused under pressures of 30, 40, and 50 cm. All of eight dogs died when infused with MO at 50 cm pressure with a mean administered dose of 1.4 +/- 0.4 cc/kg within a mean time of 87 +/- 38 min. Three of four dogs died at 40 cm pressure (1.7 +/- 0.4 cc/kg; 133 +/- 95 min) and only one of three dogs died at 30 cm pressure (2.5 cc/kg; 335 min). These dogs died from progressive hypoxia, acidosis, hemolysis, and hemorrhagic pneumonitis. Four dogs each were administered Ch at 50 and 40 cm pressure and all died with an average absorption of 19 cc/kg. Six dogs were tested with NS at 50 cm and all survived despite absorbing 180 cc/kg in 6 hr. MO at 50 cm pressure and Ch at both 40 and 50 cm pressure were significantly more toxic than saline. It is concluded that MO and Ch infused under pressure into CBD carry a significant risk of serious side effects. The infusion pressure must be monitored to prevent increased biliary pressure which might lead to intrahepatic reflux.

Animals↗
PubMed1984

Diagnosis and management of retroperitoneal hematomas after femoral vein cannulation for hemodialysis.

Six patients were identified who suffered retroperitoneal hemorrhage during or after hemodialysis via a femoral vein approach. Hypotension developing during dialysis or lower quadrant abdominal pain was the common presenting symptom. All patients had decreasing hematocrits and five of the six patients required blood transfusions. The method of diagnosis was clinical, with plain abdominal x-ray examination and cystography being the most helpful adjuncts. All patients were successfully treated with volume resuscitation and removal of the femoral vein catheters; none required operative intervention or suffered adverse late effects. Femoral vein dialysis is useful for uremic patients without other peripheral vascular access options, and its associated morbidity may be minimized provided complications are recognized and promptly treated.

Adult↗
PubMed1982

Selection of patients for dissolution of retained common duct stones with mono-octanoin.

Mono-octanoin is effective in the dissolution of retained common duct stones. Some of the failures of this solution to dissolve retained common duct stones are attributed to the low cholesterol content of the stones. This assumption was evaluated by analyzing gallbladder stones from 58 patients following cholecystectomy. Each stone was also incubated in mono-octanoin, and the composition of the stone was compared with the rate of dissolution. Stones containing 10% or less cholesterol did not appreciably dissolve in mono-octanoin. Stones 40% or greater in cholesterol content dissolved within an average of 3.3 days, which was significantly faster than those low in cholesterol (p less than 0.001). Following common duct exploration, stones should be saved for analysis or in vitro determination of the rate of dissolution in mono-octanoin. The use of mono-octanoin is recommended only for retained stones that are high in cholesterol or dissolve rapidly when incubated in mono-octanoin and should be effective in 91% of the cases.

Caprylates↗