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Biomedical subjects

L W Baker

Publications and source records attributed to L W Baker.

At least 19 recordsLinked to original sources
PubMed1992

Treatment of persistent and complicated pancreatic pseudocysts.

In a review of 1895 patients admitted with pancreatitis during a 4-year period, 241 (12.7%) were identified as having pseudocysts. The majority of these were treated without operation, but 59 patients (24.5%) needed surgical intervention because of persistence (17 cases) or development of complications (biliary obstruction in 16, infection in 12, duodenal obstruction in ten and haemorrhage in four). Most cysts (68%) resulted from alcohol-related chronic pancreatitis. Blunt abdominal trauma was the cause in three. Operations included internal drainage in 35 (cystogastrostomy in 23, cystojejunostomy with Roux-en-Y in ten and cystoduodenostomy in two), external drainage in 20, pancreatic resection in two, and gastroenteric or bilioenteric bypass in ten. There were six postoperative deaths (10.2%), one after internal drainage (3%) and 5 (25%) after external drainage (P < 0.01, Fisher's exact test). Pseudocyst decompression failed to relieve biliary obstruction in half of the patients and biliary-enteric anastomosis was necessary because of a stricture in the distal bile duct. Massive bleeding from pseudocyst-related false aneurysms was successfully controlled by transcatheter angiographic embolization in four patients. During 1-5 years' follow-up, 24 of the 53 surviving patients (45%) were readmitted with pancreatitis and three of these died. Pseudocysts recurred in three patients, with spontaneous resolution in two and need for operation in one. It is concluded that operative treatment of complicated pseudocysts carries a substantial mortality rate. The need for additional biliary-enteric bypass after cyst decompression should be carefully assessed during operation. Angiographic embolization of pseudocyst haemorrhage is a valuable therapeutic manoeuvre.

Acute Disease↗
PubMed1992

Management options in malignant obstruction of the left colon.

Three of every 20 patients with carcinoma of the colon present with obstruction. The prognosis in the patient with malignant left colon obstruction is worse than for those with nonobstructing lesions, without adding the burden of a colostomy. Whenever feasible, acute obstruction should be treated by definitive resection with primary anastomosis and staged procedures reserved for only a few. How the former is achieved is open to debate. Whether or not the removal of all fecal matter from the colon is necessary before anastomosis is questionable and needs further appraisal. The risk of a metachronous lesion developing is highest in young patients with polyps or a previously resected carcinoma. The high risk patients would be best served by a subtotal colectomy. The choice of procedure must be tailored to each patient and the final decision made at the time of operation. An experienced colonic surgeon is needed to judge which option is most appropriate.

Carcinoma↗
PubMed1990

Colon wound management and prograde colonic lavage in large bowel trauma.

Between 1983 and 1987 prograde colonic lavage was prospectively evaluated in 389 patients with colon trauma. Predefined high risk patients had exteriorization of the primarily sutured colon. Intraperitoneal primary closure was otherwise used. Patients received prograde colonic lavage by random allocation. The healing exteriorized colon was interiorized 5-10 days after the initial surgery. The median age was 29 years and only 28 patients were women. Injuries were due to stab (316), gunshot (54), shotgun (10) or blunt trauma (9). Exteriorization of the primarily sutured colon was carried out in 217 patients of whom 101 had prograde colonic lavage. Twenty (9 per cent) died. Of the survivors, 150 (76 per cent) had their colon successfully interiorized and this rate was unaffected by prograde colonic lavage. Intraperitoneal primary closure was performed in 172 patients of whom 91 had prograde colonic lavage. Seven (4 per cent) died. Mortality was directly related to the number of associated injuries. Prograde colonic lavage, irrespective of the type of colonic wound management used, did not reduce the mortality rate, which was 7.2 per cent for those who had such lavage and 6.6 per cent for the rest. Prograde colonic lavage cannot therefore be recommended in colon trauma.

Adolescent↗
PubMed1988

Management of severe intra-abdominal sepsis: single agent antibiotic therapy with cefotetan versus combination therapy with ampicillin, gentamicin and metronidazole.

In a prospective, randomized trial involving 100 patients with severe intra-abdominal sepsis, the value of single agent antibiotic therapy with cefotetan was compared with that of combination therapy of ampicillin, gentamicin and metronidazole (AGM). All patients underwent exploratory laparotomy. The mortality rate was 3 per cent, all deaths occurring within 48 h of operation. Two-thirds of patients were considered severely ill on admission, and one-third were moderately ill. Six patients had positive blood cultures on entry into the study. The mean age was 31 years and concurrent disease was present in 14 per cent of the patients. A satisfactory response was achieved in 82 per cent of patients receiving cefotetan and in 65 per cent of those receiving AGM, whereas the response was unsatisfactory in 18 per cent of cefotetan patients and 35 per cent of those receiving AGM (P = 0.075 n.s.). Significant changes in laboratory values during the study occurred in 51 per cent of patients, and 7 per cent required vitamin K administration for hypoprothrombinaemia. The results of this study suggest that antibiotic therapy with single agent cefotetan is as safe and effective as a combination of ampicillin, gentamicin and metronidazole in patients with severe intra-abdominal sepsis requiring operative management.

Abdomen↗
PubMed1987

Selective management of abdominal and thoracic stab wounds with established peritoneal penetration: the eviscerated omentum.

In a prospective study involving 276 patients, stab wounds to the abdomen and lower chest with certain penetration into the peritoneal cavity were managed selectively. On the basis of physical findings, patients underwent either immediate laparotomy or close observation with frequent reexaminations and operation only if signs changed. The reliability of physical examination and the safety of nonoperative treatment in the absence of peritoneal signs were assessed. The overall incidence of major damage, including damage to the diaphragm, was 59.1 percent. Significant intraperitoneal visceral injury was found in 45.7 percent of patients with transabdominal stab wounds and in 25 percent of those with transthoracic stab wounds. Physical examination correctly predicted the findings in 90 to 96 percent of patients at initial assessment, with a sensitivity of 88.4 percent and a specificity of 93.9 percent. As delayed laparotomy after a change in signs during observation did not increase morbidity or hospital stay, and the unnecessary laparotomy rate in this study was 5.9 percent, we recommend a policy of selective management of abdominal and thoracic stab wounds with omental evisceration or other evidence of peritoneal penetration. Local wound care with amputation of the protruded omentum followed by close observation and monitoring of vital signs is safe surgical practice when no peritoneal signs or other indication for urgent exploration are present on admission.

Abdominal Injuries↗
PubMed1985

Vascular occlusion in the pathogenesis of complicated amoebic colitis: evidence for an hypothesis.

Amoebic perforation of bowel, the final and most serious manifestation of transmural amoebic colitis, is due to thrombotic occlusion of vessels supplying the segment of bowel with subsequent infarction and ischaemic necrosis. The ischaemic nature of the necrosis is confirmed by its shape and the demonstration of vascular thrombosis in the resected specimens of perforated amoebic colitis. Specimen angiography confirms the avascular area confined to the macroscopic lesions. Thrombotic occlusion and amoebic invasion of blood vessels have been demonstrated histologically. This new information suggests that amoebic perforation of the bowel is due to vascular compromise.

Angiography↗
PubMed1985

Management of splenic trauma: the Durban experience.

In a retrospective survey of splenic trauma managed at a teaching hospital, the data of 127 patients during a 2 year period have been analysed. Splenic conservation was achieved in 47 laparotomies (38.8 per cent). Six patients with blunt abdominal trauma (4.7 per cent of all patients) were managed non-operatively. Splenic conservation by suture with or without packing with omentum or oxidized cellulose was successful in 27 out of 37 attempts. Failure of this technique was easily recognized during laparotomy and no patient required re-operation for continued splenic bleeding after splenorrhaphy. There was no significant difference between successful conservation of the spleen at laparotomy of patients below the median age (28 years) and older patients. Wound sepsis was increased after splenectomy (P less than 0.05). Splenic conservation is not appropriate for all types of splenic injury. Where conservation is not possible splenectomy and re-implantation is recommended.

Adolescent↗
PubMed1985

Esophageal transection versus injection sclerotherapy in the management of bleeding esophageal varices in patients at high risk.

In a prospective randomized trial of 76 patients at high risk with bleeding esophageal varices, transection of the esophagus with the EEA stapling apparatus was compared with injection sclerotherapy in the management of patients with Child's class B and C liver status. Thirty-nine patients underwent transection and 37 patients, sclerotherapy with a total of 92 injection procedures (2.4 per patient). The perioperative mortality (less than 30 days) was 28.9 per cent overall; 33.3 per cent for esophageal transection and 24.3 per cent for injection sclerotherapy (chi 2 = 0.375, p greater than 0.05). Gross ascites, severe encephalopathy and emergency operations were associated with a high mortality in the transection group, but other risk factors such as age and hypersplenism did not influence the outcome in either group. Only patients in Child's class C died after transection, but patients who died in the sclerotherapy group (mainly from recurrent bleeding) included patients from both Child's class B and C. Early recurrence of nonfatal bleeding affected one of 39 patients (2.5 per cent) after transection but was evident in 18 of 37 patients (48.6 per cent) after sclerotherapy (chi 2 = 19.12, p greater than 0.0005) and six patients died. Hemorrhage did not recur after transection during a follow-up period of two years, but a further 22 episodes of bleeding were recorded in 13 patients receiving sclerotherapy with five deaths. Postoperative complications and long term morbidity were similar in the two groups. Including readmissions for bleeding and repeat procedures, the mean hospital stay per patient was shorter for transection (14.5 versus 19.1 days) and the requirements for blood were less (1.9 units per patient versus 3.6 units per patient) than for sclerotherapy. It is concluded that esophageal transection effectively protects against short term recurrence of bleeding. Preoperative control of gross ascites will further reduce the mortality and comatose patients should be excluded from operation. Sclerotherapy provides little if any protection against recurrent bleeding and its use in the management of variceal hemorrhage in patients with advanced liver disease remains questionable. It is recommended as a temporary measure in patients at high risk until such time that more effective surgical treatment can be performed.

Adolescent↗
PubMed1979

Late revascularization of the lower limb following acute arterial occlusion.

Thirty-four patients presenting with signs of grave ischaemia of the lower limb following acute arterial occlusion had revascularization procedures performed. Fifteen of the incidents followed embolism or thrombosis and 19 were due to a traumatic cause. Limb salvage was achieved in 67 per cent of the nontraumatic group and in 56 per cent of the traumatic group. Severe complications such as crush syndrome and disseminated intravascular coagulation occurred but there were no deaths. No significant adverse factors with regard to limb prognosis could be defined. We feel that late revascularization in the absence of major gangrene is worth while provided that facilities for critical postoperative care exist.

Adolescent↗
PubMed1978

Diminished cellular immunity due to impaired nutrition in oesophageal carcinoma.

The nutritional status of 15 Negro patients suffering from unresectable carcinoma of the midthoracic oesophagus was evaluated before and after palliative pulsion intubation. All were shown to be in negative nitrogen balance and to have a compromised non-specific cellular immune response. Correction of protein-calorie malnutrition and the achievement of positive nitrogen balance were associated with an increase in absolute lymphocyte and T lymphocyte numbers and a significant increase in lymphocyte response to PHA. The improvement in immunological reactivity occurred without any attempt at therapeutic reduction in tumour bulk.

Adult↗
PubMed1978

Major arterial trauma: review of experience with 267 injuries.

Experience with 267 arterial injuries treated over a 3--4-year period is reported. Vessels in the lower limb were involved most commonly (43 per cent), but there was also a relatively high incidence of carotid (13 per cent) and subclavian (9 per cent) injuries in this series. Penetrating wounds (stab and gunshot) were most commonly responsible. We found that serious distal ischaemia is uncommon in upper limb injuries, but expanding haematoma at the root of the limb is a cause of mortality and serious morbidity. Selective use of preoperative angiography is recommended. Successful results follow liberal use of interposition grafts after wide excision of doubtful vessel, rigorous wound excision, delayed primary closure and fixation of associated fractures. Repair of concomitant venous injuries should always be attempted but is more important in the lower than the upper limb. Late revascularization in the presence of critical ischaemia yields a 50 per cent limb salvage rate, but great care must be taken to avoid renal insufficiency and, if it occurs, energetic treatment is necessary for survival.

Adult↗
PubMed1978

Colorectal carcinoma in young black patients: a report of eight cases.

Colorectal carcinoma in the black population of South Africa is very uncommon when compared with incidence among whites. Even in whites the proportion of patients with colorectal carcinoma under 25 years of age is less than 1% (Hardin, 1972). Eight cases of colorectal carcinoma in black patients under 25 years of age are presented. None had any evidence of premalignant lesions of the colon. The prognosis of colorectal carcinoma in young adults is poor in most series and this group of patients was no exception. Reasons for this poor prognosis are mentioned. A more aggressive approach to the early detection and treatment of the lesion in young patients is essential.

Adenocarcinoma, Mucinous↗
PubMed1978

Delayed presentation of traumatic diaphragmatic hernia.

Twenty-five patients with traumatic diaphragmatic hernia discovered at least five months after injury are described, of whom 18 were male and seven female. All but one hernia occurred on the left side. Stab wounds were the etiological factor in 22 patients and blunt trauma in three. The diagnosis was most often made by a chest or abdominal radiograph, but barium ingestion confirmed the diagnosis in ten patients. Intercostal drainage of gastric contents provided the diagnosis in two patients. In all nine patients initially approached by a thoracotomy or a thoracoabdominal incision, the hernia was easily reduced and the defect repaired. Although reduction and repair were easily accomplished by the abdominal route in seven patients, this approach was unsatisfactory or inadequate in six others. The colon and stomach were usually in the chest, and strangulation occurred in five patients. The mortality was 20% but rose to 80% when gangrene was present.

Adult↗