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Biomedical subjects

L W Traverso

Publications and source records attributed to L W Traverso.

At least 73 records · Page 4Linked to original sources
PubMed1994

Laparoscopic cholecystectomy. Do preoperative factors predict the need to convert to open?

We reviewed our experience with the last 587 laparoscopic cholecystectomies performed between May 1990 and January 1993 to correlate preoperative findings that may predict the conversion of a laparoscopic cholecystectomy to that of an open procedure. The prediction of a need to convert to an open cholecystectomy would allow the surgeon to discuss the higher risk of conversion with the patient and also allow for an earlier intraoperative decision to convert if difficulty was encountered. In addition to routine demographic data, ultrasound reports were available for 526 patients and the following information was recorded: presence of stones, thickened gallbladder wall, common bile duct dilatation, gallbladder sludge, and cystic duct impaction. Overall, a two times higher rate of conversion was found for male patients and patients with a body mass index > 27.2 kg/m2. Additionally, a thickened gallbladder wall on preoperative ultrasound was correlated with a six times higher conversion rate to open cholecystectomy. As expected, the positive intraoperative cholangiogram was associated with a higher incidence of conversion. Additionally, finding a dilated common bile duct on ultrasound was found to be associated with a nearly seven times higher rate of positive intraoperative cholangiogram. No statistical significance was found between conversion and age, previous abdominal operations, the presence of stones, common bile duct dilatation, gallbladder sludge, cystic duct impaction, or a distended gallbladder. Thus, these predictive findings allow the surgeon to preoperatively discuss the higher risk of conversion and allow for an earlier judgment decision to convert if intraoperative difficulty is encountered.

Acute Disease↗
PubMed1994

Characteristics of biliary tract complications during laparoscopic cholecystectomy: a multi-institutional study.

We collected the records of 81 patients with biliary tract injuries occurring during laparoscopic cholecystectomy (LC) who were referred to 3 referral centers during a 33-month (May 1990 to March 1993) period. All records were reviewed to provide data concerning the anatomy of the lesion induced, method of injury, timing of injury detection, role of intraoperative cholangiography (IOC), methods of treatment, and outcome of these injuries. Injuries were classified by our own method as follows: (1) cystic duct leaks (n = 15), (2) bile leaks and/or ductal strictures (n = 27), and (3) ductal transections or excisions (n = 39). Peak occurrence by quarter of the year was 4th quarter, 1990 (Lahey), and 3rd quarter, 1991 (Mason), and 1st quarter, 1992 (Mayo). The majority (62%) of the injuries were recognized after LC. At the time of LC, 31 of 81 (38%) injuries were recognized and converted to open procedures. Data regarding IOC were available in 63 of 81 (78%) cases. In patients in whom IOC was not performed, 14 of 38 (37%) operations were converted; if an IOC was obtained and interpreted correctly, 13 of 21 (62%) operations were converted. Primary repair was attempted in 11 leaks and/or strictures, but 36% required additional treatment. Primary repair was used in six transections or excisions, and 17% have required further intervention. In patients who had biliary-enteric bypass (BEB) performed outside (17) versus at the referral institution (29), 94% (16 patients) versus 0%, respectively, required additional operative (e.g., revision of a hepaticojejunostomy) or nonoperative (e.g., radiologic or endoscopic stenting or balloon dilation) procedures. When used as initial therapy or after a primary ductal repair, stents (with or without balloon dilation) resolved 100% of simple cystic duct leaks and 91% of leaks and/or strictures. In conclusion, the peak incidence of LC-related biliary injuries appears to have passed. A completed and correctly interpreted IOC increases the chance of detection of biliary injuries intraoperatively and should assist surgeons who use routine IOC. Nonsurgical techniques allow treatment of most simple cystic duct leaks, major ductal leaks and/or strictures, and postoperative BEB strictures, although follow-up is limited. The poor results of pre-referral BEB is not surprising since all of these patients were selected for referral because their treatments had not been successful.

Bile Ducts↗
PubMed1994

Routine intraoperative cholangiography and its contribution to the selective cholangiographer.

Routine intraoperative cholangiography (IOC) during cholecystectomy is controversial. In order to address this debate, we asked the following questions: What intraoperative information is provided to the surgeon? What IOC criteria or standards are necessary to observe this information? Between 1990 and 1993, 624 laparoscopic cholangiography (LC) cases were performed at Virginia Mason Hospital, during which 86% (535) of the patients underwent successfully performed IOCs. Each of these cholangiograms was sought, and 420 (78%) were reviewed by a radiologist and a surgeon. Specific items involved the presence or absence of filling defects, bile duct diameter, contrast leaks, flow into the duodenum, benign or malignant stricture, contrast in a portion of the pancreatic duct, and anomalous ducts. "Relevant findings" were defined as filling defects, stricture, leaks, and the following anomalous ducts: a bile duct from the right side of the liver entering near or into the cystic duct. The entire biliary tree was visualized in 86%, and the bifurcation was seen in 95% of the cases. Considering these deficiencies, we found a 10% incidence of filling defects. Anomalies were common in the biliary tree (39%), and knowledge of the presence of some of them are important for safe dissection (at least 4%). Also, at least 68 relevant findings would have been missed in 420 LC cases without IOC. If the IOC had not visualized the biliary tree proximal to the cystic duct, 30 of 68 or 44% of these findings would not have been observed. If an IOC is performed on a routine or selective basis, the study should visualize the entire biliary tree.

Adolescent↗
PubMed1994

Cystic duct leaks in laparoscopic cholecystectomy.

BACKGROUND: Cystic duct leak (CDL) appears to complicate laparoscopic cholecystectomy (LC) more often than open cholecystectomy (OC). No mention of CDL was found in a literature review that covered 48,822 OCs and their complications. PATIENTS AND METHODS: Fifty-four patients who developed biliary tract injuries following LC were reviewed for: the time from LC to presentation, presenting symptoms, method of diagnosis, treatment, outcome, and follow-up. RESULTS: Seventeen of 54 biliary tract complications (31%) were CDLs. The CDLs presented at a median of 4 days after LC with pain (76%) and nausea and/or vomiting (35%). Endoscopic retrograde cholangiopancreatography (ERCP) defined the diagnosis and the anatomy of the leak in 11 patients (65%). Biliary endoprosthesis placement was employed in 8 patients, with concomitant sphincterotomy in 5 (63%), and resolved CDL in every case. Seven (88%) of these patients were asymptomatic at a median interval of 10 months after stent retrieval. Six patients (35%) underwent reoperation. Five had laparotomy with ligation of the cystic duct stump and 1 underwent laparoscopic examination with reclipping of the cystic duct stump. Five (83%) were asymptomatic at a median follow-up of 26 months. CDLs may result from inaccurate clip placement, perforations proximal to the clips, and stump necrosis, as documented at reoperation. CONCLUSIONS: CDLs occur more frequently in LC than in the OCs reported in the literature. Most leaks require intervention. ERCP with stent placement is the diagnostic and therapeutic procedure of choice and has a high success rate of resolving leaks. To forestall CDLs, it is important to place clips accurately and avoid electrocautery in the vicinity of the cystic duct.

Bile Ducts↗
PubMed1994

Endoscopic treatment of pancreatic ascites.

Pancreatic ascites, etiologically related to a leaking pseudocyst or ductal disruption, has been treated medically with hyperalimentation, somatostatin analog, and large-volume paracentesis. Surgery is ultimately required in more than 50% of such patients. Mortality figures in patients with pancreatic ascites approximate 15% to 25% with either treatment modality. We describe 4 patients who were found to have ductal disruptions in conjunction with pancreatic ascites who responded to transpapillary pancreatic duct endoprosthesis placement. There has been no recurrence of ascites in these patients at a mean follow-up of 12 months following stent-retrieval. Further evaluation of endoscopic therapy for pancreatic ascites appears warranted.

Adult↗
PubMed1993

The Whipple procedure for severe complications of chronic pancreatitis.

OBJECTIVE: To analyze the clinical indications and long-term results for the Whipple procedure used for severe complications of chronic pancreatitis (CP). DESIGN: A series of 28 patients requiring the Whipple procedure for CP were reviewed by one surgeon between 1986 and 1993. SETTING: A multispecialty group practice hepatobiliary pancreatic referral center. PATIENTS: The referred patients with CP complications in the pancreatic head were anatomically defined by endoscopic retrograde cholangiopancreatographic and computed tomographic scans to include expanding pseudocysts, pancreatic duct disruption, arteriovenous fistula, or calcified obstructive fibrosis of bile duct, pancreatic duct, and/or duodenum. INTERVENTION: The Whipple procedure (pylorus-preserving [n = 25] or standard [n = 3]) was performed after preoperative assessment with a mesenteric arteriogram and, as necessary, percutaneous drainage or endoscopic stenting of pseudocyst, pancreatic duct, or bile duct were performed. MAIN OUTCOME MEASURES: Mortality, morbidity, length of hospital stay, and long-term results of the operation. RESULTS: There was no mortality. A 36% morbidity rate included adult respiratory distress syndrome (n = 3) secondary to a long operation time (average, 9.8 hours) or infected tissue and delayed gastric function (> 14 days) secondary to retrogastric amylase-rich fluid collections (n = 4). Long-term follow-up in 25 patients after 27 months (range, 3 to 84 months) showed that 88% were pain-free and 12% had improved. None had recurrent pancreas problems, but 28% had resumed drinking alcohol. Inability to gain weight was noted in 4% and a marginal ulcer in 4%. CONCLUSIONS: The Whipple procedure for severe complications of CP in the pancreatic head is a safe and effective operation leaving little gastrointestinal sequelae. Preoperative endoscopic and radiological assessment, drainage, and stenting procedures are key elements to achieving positive results.

Adult↗
PubMed1993

Endoscopic retrograde cholangiopancreatography after laparoscopic cholecystectomy.

We assessed the use of endoscopic retrograde cholangiopancreatography (ERCP) after laparoscopic cholecystectomy (LC) at our hepatobiliary referral center. This assessment included patients from outside institutions with post-LC problems. Between May 1990 and September 1992, we performed 522 LCs and 1,723 ERCP examinations. There were 78 patients who underwent 143 ERCP examinations after LC, 65% of whom were referred. ERCP findings were categorized as follows: normal results (8%), problems inherent to stone disease (65%), and iatrogenic injury (27%). The types of inherent problems were common bile duct (CBD) stones, pancreatitis, and papillary stenosis/microlithiasis. Within the CBD stone group, 5 of 26 patients also had papillary stenosis, and, within the pancreatitis group, 9 of 11 patients also had papillary stenosis, making papillary stenosis the most frequent observation (55%). Almost all of these patients (96%) required endoscopic papillotomy for successful treatment. The iatrogenic injury group was comprised of 21 patients, 16% of whom had cystic duct leak and 84% of whom had CBD injury. These patients required a variety of endoscopic procedures including endoscopic papillotomy (67%), CBD endoscopic stenting (76%), percutaneous drainage of biloma (29%), and percutaneous transhepatic biliary drainage (24%). Open surgical procedures after endoscopic assessment or treatment were required in only three patients in the iatrogenic group and in none in the inherent group. At this time, long-term follow-up is not possible with regard to biliary stricture. We conclude that the majority of problems after LC are either due to papillary stenosis/microlithiasis with or without CBD stones or to biliary injury. Both can be successfully diagnosed and treated with endoscopic techniques.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1993

Diagnosis and staging of pancreatic adenocarcinoma with dynamic computed tomography.

We assessed the accuracy of dynamic contrast-enhanced computed tomography (CT) in the diagnosis and staging of 213 patients with pancreatic carcinoma and compared it with the accuracy of angiography and surgery. A correct CT diagnosis of pancreatic carcinoma was made in 207 of 213 (97%) patients. Tumors were located in the pancreatic head in 64%, the body in 22%, and the tail in 10%, and enlarged the pancreas diffusely in 4%. CT staged 25 (12%) patients as having potentially resectable tumors and 188 (88%) as having unresectable tumors on the basis of local extension (72%), contiguous organ invasion (43%), vascular invasion (82%), and distant metastases (50%). Compared with angiography in 60 patients, CT detected vascular invasion missed on angiography in 20%, and angiography detected invasion missed by CT in 5%. In these latter cases, other CT criteria of unresectability were present, and angiography provided no significant staging information. Compared with surgery in 71 patients, CT accurately predicted unresectable tumors in 100% of patients and resectable tumors in 72% of patients. Eleven of the patients with CT-resectable tumors underwent resection. Median survival was 22.7 months, with four patients alive at a median of 15.5 months postoperatively. Palliative resections were performed in six patients, and median survival was 14.4 months.

Adenocarcinoma↗
PubMed1993

Preoperative visceral angiography alters intraoperative strategy during the Whipple procedure.

To determine the importance of preoperative visceral angiography prior to pancreaticoduodenectomy, all Whipple procedures performed between 1985 and 1991 at the Virginia Mason Medical Center were retrospectively reviewed. During this period, 77 pancreaticoduodenectomies were performed for both neoplastic disease (n = 54, 70%) and chronic pancreatitis (n = 23, 30%). Sixty-four preoperative angiograms were obtained, of which 39 (61%) were abnormal findings. Thirty percent (19 of 64) of the angiograms revealed a significant vascular abnormality that required specific preoperative or intraoperative measures that might not have been performed without knowledge of these findings. Examples include celiac axis revascularization for celiac occlusion, hepatic artery preservation for replaced vessels, preoperative embolization for pseudoaneurysm or arteriovenous fistula, and splenectomy for splenic vein thrombosis. Because of the high percentage of significant findings requiring an intraoperative or preoperative technical change, we recommend the use of angiography in order to diminish morbidity in all patients preparing to undergo pancreaticoduodenectomy.

Angiography↗
PubMed1993

Clinical manifestations and impact of gallstone disease.

The main symptom of gallstone disease is biliary pain. Biliary pain is not necessarily colicky or postprandial, and it most frequently occurs at night during the same clock-time. The relief of biliary pain by cholecystectomy would support the idea that the gallbladder or the stones caused pain. Long-term follow-up studies after cholecystectomy are infrequent, however. Our studies show that biliary pain is relieved in 99% of patients after 4 years of follow-up. The nonspecific symptoms associated with gallstones (i.e., dyspepsia, bloating, belching, etc.) remained in 12% of these patients. We have also shown that the gallbladder itself, without stones, can cause pain and that this biliary pain is relieved in 77% of patients by cholecystectomy. The impact of gallstones on the patient depends on the quality of cholecystectomy as classically measured by morbidity and mortality. However, quality must also be monitored by comparing the long-term relief of biliary pain and the cost. Quality cannot be monitored through inaccurate national databases or multicenter trials. Rather, the continuous quality improvement (CQI) technique of larger centralized health care systems may be the most accurate monitoring system. This technique coordinates the entire health care system by assuming that any process can improve its quality, no matter how good it may already be. Our CQI laparoscopic cholecystectomy database has yielded preliminary perspectives on accurate data collection and improving costs. After a thorough examination, 5% of the database contained cases not done laparoscopically (coding errors), whereas it missed 21% of true laparoscopic cholecystectomy cases (staff errors). Only with the accuratized database were we able to provide insight into cost-savings procedures.

Cholecystectomy↗
PubMed1993

Nesidioblastosis as a mechanism to prevent fibrosis-induced diabetes after pancreatic duct obstruction.

Does obstruction of the main pancreatic duct that results in exocrine atrophy also result in diabetes? We followed 11 mongrel dogs for 3 years after approximately three-fourths of the pancreas had been removed and the main pancreatic duct obstructed in the pancreatic tail remnant. At 3 years after surgery, all dogs showed total exocrine atrophy (remnants weighed 0.2-1.2 g). None of the animals became diabetic despite only 6% of the original pancreatic tail remaining. During the 3-year period, fasting blood insulin increased during the last half of the study, and this was associated with islets that were 1,300% larger than in control animals (nesidioblastosis). An in situ pancreatic remnant with an obstructed duct and total exocrine atrophy can maintain a nondiabetic state for > 3 years. Perhaps the mechanism is associated with the observed nesidioblastosis.

Animals↗
PubMed1993

Sparing a replaced common hepatic artery during pancreaticoduodenectomy.

A patient with a replaced common hepatic artery originating from the superior mesenteric artery successfully underwent a pylorus-sparing pancreaticoduodenectomy for chronic pancreatitis. This anomalous vessel was discovered by preoperative angiography but at operation the artery coursed ventral to the head of the pancreas, not, as one would predict, through the substance of the pancreas or dorsal to the pancreatic head and lateral to the portal vein. To our knowledge, this is the first case of a replaced common hepatic artery in this position reported in the English literature. Preservation of the entire blood supply to the liver and biliary tree is important to prevent biliary fistula after a Whipple procedure, and, in some cases, hepatic ischemia. In this case the artery was slightly larger and in the same position as the gastroduodenal artery, predisposing the patient to significant potential morbidity with a standard dissection.

Alcoholism↗
PubMed1992

Is stenting necessary for a successful pancreatic anastomosis?

The effect of stenting on pancreaticojejunostomy has not been studied in a prospective randomized trial. In 34 dogs, the left pancreatic lobe was anastomosed to a Roux-Y jejunal limb using a two-layer mucosa-to-mucosa technique. In one group (n = 12), the anastomosis was constructed over a 3F polytetrafluoroethylene (PTFE) stent, and the stent was left in situ. A second group (n = 12) had the stent removed at the completion of the anastomosis. A control group (n = 10) had the anastomosis constructed without a stent. After 1 month, autopsies were performed, and anastomoses were examined for evidence of leak, occlusion, or stenosis. No anastomotic leaks occurred when a stent was used, whereas one (10%) occurred when no stent was used. No occlusions occurred in the two groups with stents, but two (20%) occurred in the no-stent group. Stenosis rates were 0% in the stent-in group, 25% in the stent-out group, and 30% in the no-stent group. Although no comparisons were statistically significant, there was a trend. Anastomoses performed over a stent, whether or not the stent was left in situ, had lower rates of leak, occlusion, and stenosis. We believe, but cannot prove, that a stent improves anastomotic integrity and patency by facilitating exact placement of mucosal sutures.

Anastomosis, Roux-en-Y↗
PubMed1992

Infections complicating severe pancreatitis.

Infections accompanying severe pancreatitis are secondary and of three types: infected pancreatic necrosis, infected pseudocyst (including peripancreatic fluid collection), and pancreatic abscess. The first is an earlier, more morbid process, with antibiotics supportive and surgical debridement necessary. The latter two processes occur later in the course of pancreatitis and are less morbid. Antibiotics are supportive and invasive-nonsurgical drainage methods are possible. The decision for intervention is based first on clinical toxicity as determined by an overall assessment by the clinician. The presence of parenchymal necrosis is best determined by the dynamic bolus CT scan. The presence of infection is best determined by percutaneous CT-guided aspiration. Infected necrosis is fatal unless treated with operative intervention. A peripancreatic fluid collection, pseudocyst, or pancreatic abscess needs to be treated if symptomatic. If infected, as determined by CT-guided needle aspiration, then they should be drained. Radiologic or endoscopic invasive-nonsurgical methods are tried initially and then surgery is attempted if they fail. The nonsurgical methods are most successful with pancreatitis of a nonbiliary or a nonalcohol etiology.

Humans↗
PubMed1992

Pancreaticoenteric fistula: no longer a surgical disease?

We report our experience with eight patients with severe persistent pancreatitis associated with peripancreatic fluid collections requiring placement of drainage catheters who subsequently developed pancreatic fistula. The fistulas were diagnosed by endoscopic retrograde cholangiopancreatography, contrast tube study, or Hypaque enema at a mean of 13 weeks after diagnosis of pancreatitis and drain placement. These fistulas involved the duodenum in five patients and colon in three patients. Six patients had fistula resolution with medical therapy (after removal of percutaneous drainage catheters in three and with drain removal in conjunction with transpapillary stenting of a disrupted pancreatic duct in another three). We conclude that in patients with ongoing pancreatitis, pancreaticoenteric fistulas are probably caused by erosion of percutaneous drainage catheters. Such fistulas resolved with conservative treatment in six of eight patients.

Catheters, Indwelling↗
PubMed1991

Wound complications after modified radical mastectomy compared with tylectomy with axillary lymph node dissection.

Tylectomy with axillary lymph node dissection and radiotherapy (TAD) has become an accepted treatment for early breast cancer and has been shown to result in equal 5- and 8-year survival when compared with modified radical mastectomy (MRM). In order to determine the safety of TAD with respect to wound complications and to identify potential risk factors, we reviewed the charts of 560 patients undergoing MRM (n = 387) and TAD (n = 173) at Virginia Mason Medical Center from 1983 through 1989. The incidence of infection, seroma, hematoma, and epidermolysis were compared, and obesity, age 60 years or older, smoking, antibiotics, and wound drainage were examined as possible risk factors. There were more wound complications in the MRM group versus the TAD group (49% versus 35%; p less than 0.01), specifically more seromas (29% versus 18%; p less than 0.01) and epidermolysis (18% versus 0%). In the MRM group, age 60 years or older was associated with seroma (p less than 0.01) and smoking was associated with epidermolysis (p less than 0.01). In the TAD group, obesity was associated with infection. In both groups, volume of drainage from closed suction wound drains greater than 30 mL in the 24 hours prior to removal of the last drain was associated with seroma (p less than 0.05).

Axilla↗
PubMed1991

Invasive treatment of pancreatic fluid collections with surgical and nonsurgical methods.

Pancreatic fluid collections (PFC) can be drained surgically or nonsurgically with endoscopic or radiologic techniques. To define subgroups of patients with PFC who would benefit from the new modalities, we reviewed a period (1977 to 1990) during which both surgical and nonsurgical invasive techniques were available. Patients with phlegmon or necrosis at initial diagnosis were excluded. Sixty-five patients (35 male, 30 female) underwent 1 or more drainage procedures. A mean postprocedure follow-up of 10.2 months was available for 59 patients. Initial management was nonsurgical in 80% of patients. Procedures in patients with follow-up comprised invasive nonsurgical drainage (n = 25), invasive nonsurgical drainage plus surgery (n = 22), and surgery only (n = 12). Results for each group, respectively, were: morbidity, 20%, 20%, and 24%; mortality, 8%, 5%, and 0%; and successful drainage, 92%, 82%, and 83%. The choice of management appeared to be based on etiology and radiologic characteristics. Patients with nonalcohol- and nonbiliary-associated pancreatitis without a radiographically defined wall were more common in the invasive nonsurgical group and were successfully treated without surgery. Nonsurgical invasive techniques are efficacious in the treatment of PFC in this subgroup of patients.

Exudates and Transudates↗