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Biomedical subjects

L W Traverso

Publications and source records attributed to L W Traverso.

At least 91 records · Page 5Linked to original sources
PubMed1991

Endoscopic transpapillary therapy for disrupted pancreatic duct and peripancreatic fluid collections.

Eighteen patients with active pancreatic ductal disruptions, including 14 with definable fluid collections, were treated with transpapillary pancreatic duct drains or stents. Twelve of these patients had undergone a previous percutaneous or surgical pancreatic drainage procedure or both, and 8 had long-term drainage tubes in chronic fistulous tracts. Transpapillary catheters could be placed across the ductal disruption or directly into the fluid collection in each case, and 16 of 18 patients had resolution of the disrupted pancreatic duct. Twelve of 14 fluid collections resolved. Complications were limited to mild exacerbation of pancreatitis symptoms in 2 patients and 2 patients who developed subsequent stent occlusion leading to recurrent pancreatitis (1 patient) or recurrent duct blowout with pseudocyst (1 patient). Nine patients had variably significant ductal changes attributable to pancreatic duct stents. At a median follow-up of 16 months, 7 patients ultimately required surgery for ongoing pancreatic pain or residual/recurrent fluid collection. The transpapillary treatment of ongoing pancreatic ductal disruption with or without fluid collection has the potential to obviate surgery in some patients, change an urgent surgical procedure into an elective one, or even assist the surgeon in the performance of intraoperative pancreatography. Further study of this technique appears warranted and must be placed into the perspective of current therapies.

Acute Disease↗
PubMed1990

Immediate breast reconstruction following mastectomy is as safe as mastectomy alone.

We evaluated wound complications and potential risk factors after mastectomy with immediate breast reconstruction and compared them with similar data after modified radical mastectomy. The incidences of infection, seroma, hematoma, and epidermolysis were compared among 395 patients (305 with modified radical mastectomies and 90 with mastectomy with immediate breast reconstruction) from Virginia Mason Medical Center, Seattle, Wash, between 1983 and 1989. Obesity, age (60 years or older), smoking, antibiotics, and wound drainage were examined as possible risk factors. There were more wound complications in the modified radical mastectomy group (48% vs 31%), and specifically, more seromas (30% vs 13%). In the modified radical mastectomy group, age of 60 years or older was associated with seroma and infection, drainage greater than 30 mL per day (at time of drain removal) with seroma, and smoking with epidermolysis. In the mastectomy with immediate breast reconstruction group, obesity was associated with seroma and epidermolysis. We conclude that mastectomy with immediate breast reconstruction appears to be as safe as modified radical mastectomy alone with respect to wound complications.

Age Factors↗
PubMed1990

Cholecystectomy provides long-term symptom relief in patients with acalculous gallbladders.

Elective cholecystectomy was performed in 60 patients with biliary colic and acalculous gallbladders during a 5-year period. Gallbladder wall disease was significantly more common (p less than 0.01) in patients with acalculous gallbladders than in a similar symptomatic group with calculous gallbladders. Thirty-four of 43 patients (77%) available for long-term follow-up reported complete symptom relief after cholecystectomy. Preoperative ultrasonography, biliary scintigraphy, oral cholecystography, upper gastrointestinal series, and pathologic features of the gallbladder were equivocal in predicting long-term symptom relief. In patients with acalculous biliary colic, the best predictor of complete symptom relief is an adequate history of true biliary colic.

Adult↗
PubMed1990

Modern standards for comparison of cholecystectomy with alternative treatments for symptomatic cholelithiasis with emphasis on long-term relief of symptoms.

Cholecystectomy is standard treatment for symptomatic cholelithiasis. Long term relief from symptoms, however, has not been reported. We reviewed 671 elective cholecystectomies performed between 1982 and 1987 for biliary colic (group 1, 91 per cent), dyspepsia associated with gallstones (group 2, 5 per cent) and atypical pain syndromes (group 3, 4 per cent), to define precisely important variables for comparison with alternate methods of gallstone treatment. Cholecystectomy resulted in a mortality rate of zero per cent and an over-all morbidity rate of 4.5 per cent. The procedure-related morbidity rate was 2.2 per cent. Long term follow-up period for 81 per cent of these patients (mean of 45 months) showed that 88 per cent were free of symptoms. Patients in groups 1 and 3 were more likely to obtain relief from symptoms than those in group 2 (p = 0.10). We concluded that cholecystectomy is a definitive treatment for symptomatic cholelithiasis with minimal risk to the patient and a high degree of relief from symptoms. Alternative treatments for gallstones must compare favorably with these results of modern cholecystectomy prior to acceptance and widespread use.

Cholecystectomy↗
PubMed1989

Failure of somatostatin or an analog to promote closure of end pancreatic fistulae.

Somatostatin has been reported to promote closure of pancreatic fistulae, but use of the analog SMS 201-995 (Sandoz, Inc.) has not previously been published. We used this analog to treat two patients with end pancreatic fistulae refractory to conventional therapy. One patient had disruption of a pancreaticojejunostomy after pancreaticoduodenectomy and the other had acute necrotizing gallstone pancreatitis and disruption of the pancreatic duct in the tail. SMS 201-995 (100-150 micrograms/d) abruptly decreased fistula output by 50% in both patients but further increases in dosage had no further effect on output. Neither fistula healed after 3-4 wk of therapy. Treatment with somatostatin or its analogs alone will not lead to closure of a pancreatic fistula complicated by factors such as distal obstruction, infection, or foreign body. Somatostatin may promote closure of lateral fistulae and may simplify the management of patients with high output fistulae.

Adenocarcinoma↗
PubMed1989

Endoscopic placement of pancreatic stents and drains in the management of pancreatitis.

Although widely used in the biliary tree, little data is available on endoscopic placement of stents or drains within the pancreas. This report describes 17 patients, nine with acute relapsing pancreatitis and eight with chronic pancreatitis, who had drain or stent placement for hypertensive pancreatic duct (PD) sphincter, dominant ductal stenosis, duct disruption, or pseudocyst. Two patients have subsequently undergone surgery, and six other patients continue long-term stent placement with marked reduction of chronic pain or attacks of recurrent pancreatitis. All six pseudocysts resolved, although one recurred and required surgery. It is concluded that pancreatic drains or stents may obviate the need for surgery, temporize before definitive therapy, or direct a subsequent surgical procedure.

Acute Disease↗
PubMed1989

Pancreaticoduodenectomy. The importance of preserving hepatic blood flow to prevent biliary fistula.

The arterial blood supply to the common bile duct must be preserved during pancreaticoduodenectomy to avoid ischemic breakdown of the biliary-enteric anastomosis. Interruption of this blood supply can occur during operation because of inadvertent division of the common hepatic artery or a hepatic artery variation. Approximately 17 per cent of patients have a hepatic artery variation that could contribute to devascularization of the common bile duct during surgical resection of the pancreatic head. This report discusses these hepatic artery variations and the value of angiography in defining hepatic arterial anatomy prior to surgery. Two cases are presented in which biliary-enteric anastomoses became ischemic and dehisced secondary to interruption of hepatic arterial blood flow.

Aged↗
PubMed1988

Intrapancreatic communication of bile and pancreatic ducts secondary to pancreatic necrosis.

An unusual complication of acute necrotizing pancreatitis occurred in which erosion of the intrapancreatic common bile duct and cephalic pancreatic duct formed a pancreaticobiliary cavity. This pancreatic process was observed to enhance during contrast computed tomography and was hypervascular during angiography, making preoperative diagnosis difficult. To our knowledge, the spontaneous development of such a cavity as a complication of acute pancreatitis has not been reported. The patient was successfully treated with pancreaticoduodenectomy.

Acute Disease↗
PubMed1988

Surgical versus endoscopic management of common bile duct stones.

The charts of all patients with common bile duct (CBD) stones admitted to Virginia Mason Medical Center between January 1, 1981 and July 31, 1986 were reviewed to define current methods of management and results of operative versus endoscopic therapy. Two hundred thirty-seven patients with CBD stones were treated. One hundred thirty patients had intact gallbladders. Of these patients, 76 (59%) underwent cholecystectomy and common bile duct exploration (CBDE) while 54 (41%) underwent endoscopic papillotomy (EP) only. Of the 107 patients admitted with recurrent stones after cholecystectomy, all but five were treated with EP. The overall mortality rate was 3.0%. Complications, success, and death rates were all similar for CBDE and EP, but the complications of EP were often serious and directly related to the procedure (GI hemorrhage, 6; duodenal perforation, 5; biliary sepsis, 4; pancreatitis, 1). Patients undergoing EP required significantly shorter hospitalization than those undergoing CBDE. Multivariate analysis showed that age greater than 70 years, technical failure, and complications increased the risk of death, regardless of procedure performed. Twenty-one per cent of those undergoing EP with gallbladders intact eventually required cholecystectomy. The conclusion is that the results of EP and CBDE are similar, and the use of EP has not reduced the mortality rates of this disease.

Adult↗
PubMed1988

Pancreatic ductal adenocarcinoma: diagnosis and staging with dynamic CT.

The authors assessed the accuracy of dynamic computed tomography (CT) in diagnosis and staging of ductal adenocarcinoma of the pancreas and analyzed the survival rates of patients with resectable and unresectable tumors. A correct diagnosis based on CT findings was made in 159 of 174 patients (91%) with 13 false-positive (8%) and two false-negative diagnoses (1%). The 13 false-positive diagnoses highlight the need for confirmation of diagnosis with biopsy. The accuracy of staging with CT was compared with that of angiography (42 patients) and surgery (51 patients). CT was more accurate than angiography in demonstrating tumor involvement of major peripancreatic vessels. Staging criteria were reliable: No unresectable tumors based on CT findings were found to be resectable during surgery (42 patients), while only three of nine resectable tumors based on CT findings were found to be unresectable. Thus, no tumors were incorrectly staged, which would potentially deny surgery for a patient. The average survival rate after resection was 14 months, while the survival rates after palliative (biliary or gastrointestinal bypass) or no treatment were 8 months and 5 months, respectively.

Angiography↗
PubMed1988

Infected pancreatic fluid collections: percutaneous catheter drainage.

Thirty-eight infected pancreatic fluid collections in 23 patients with acute or chronic pancreatitis were drained percutaneously following initial diagnosis with computed tomography and fine-needle aspiration. Fifteen (65.2%) patients were cured completely without surgery. Eight (34.8%) patients required some type of surgery despite successful treatment of the fluid collection, and in two (6.5%) the collection recurred after catheter removal. Complications occurred in three (13%) patients, but only one complication (4%), empyema, was a direct result of catheter drainage. Catheter drainage time averaged 29 days for 16 patients with isolated collections and 96 days and 104 days for patients with collections with pancreatic duct fistulas (nine patients) or gastrointestinal fistulas (14 patients), respectively. This study confirms that infected pancreatic fluid collections can be safely and effectively treated with percutaneous catheter techniques in most patients.

Abscess↗
PubMed1988

Nonoperative versus operative treatment of obstructive jaundice in pancreatic cancer: cost and survival analysis.

Pancreatic carcinoma is complicated by malignant obstructive jaundice in 40-70% of cases. Patients frequently are old, debilitated, unresectable, and faced with a dismal prognosis. Invasive endoscopic and radiologic procedures in the inoperable patient can provide palliation without the need for surgery, in most cases. Few studies have compared nonoperative palliation with conventional surgical biliary enteric bypass procedures. In a retrospective study of patients with pancreatic carcinoma, we found no difference between operative and nonoperative treatment in survival, total hospitalization, or morbidity and mortality. Cost analysis revealed significant savings with nonoperative treatment.

Aged↗
PubMed1987

Pancreatic juice in the peritoneal cavity: antibiotics or omental preservation prevent mortality.

Pancreatic juice without bile will accumulate if the pancreatic duct communicates with the peritoneal cavity. We tested the effect of antibiotics or omentectomy on mortality in dogs where the pancreatic duct drained into the peritoneal cavity. Under sterile conditions the head of the pancreas was excised, the duodenum was preserved, and the body and tail of the pancreas remained in situ. The pancreatic duct was either ligated or left open to drain into the peritoneal cavity. Thirty-two dogs were prepared and divided into four groups by the status of the pancreatic duct, the use of omentectomy, or the administration of two doses of penicillin G procaine (20,000 units/kg) given before and then 24 hr after operation. The dogs were observed for mortality over a 1-month period. If a mortality occurred, the etiology was determined at autopsy. After excision of the omentum, the mortality rate was significantly higher if the pancreatic duct was allowed to drain into the peritoneal cavity than if the duct was ligated. Mortality decreased within the duct open group if only antibiotics were given (significant) or if only the omentum was preserved (not significant). This study indicates the importance of bacterial contamination or omental function when pancreatic juice is present in the peritoneal cavity.

Abscess↗
PubMed1987

Hypertonic sodium chloride solutions: effect on hemodynamics and survival after hemorrhage in swine.

We evaluated the hemodynamic response of 12% shed blood replacement with 7.5% sodium chloride after a nonlethal hemorrhage in chronically instrumented swine. Compared to no treatment or Ringer's lactate infusion, the hypertonic salt solution was followed by increased cardiac output. We then evaluated the effect of hypertonic sodium chloride on survival after an otherwise lethal hemorrhage in chronically instrumented and unanesthetized swine. Survival was significantly greater after replacement of 25% of the shed blood with 7.5%, but not with 0.9%, 5.0%, or 10.0% sodium chloride solution. The mechanism appears to be by increased tissue perfusion as indicated by lower lactate values. Resuscitation with low-volume hypertonic sodium chloride may be life saving and life supporting during the initial treatment of trauma patients when conventional therapy is not available.

Animals↗
PubMed1986

Fluid resuscitation after an otherwise fatal hemorrhage: I. Crystalloid solutions.

One half of deaths among trauma victims occur within 1 hour of injury and are due to rapid hemorrhage or CNS trauma. We developed a rapid hemorrhage model in unanesthetized swine to simulate human exsanguination. We compared the ability of four crystalloid solutions to prevent death after an otherwise fatal hemorrhage: normal saline (NS), Ringer's lactate (RL), Plasmalyte-A (PA), and Plasmalyte-R (PR). Five days before hemorrhage swine received an aortic sideport and a central venous treatment catheter. Aortic blood (54 ml/kg) was removed in 15 minutes from 116 swine. The percentages of shed blood replaced were 14% in 5 minutes with NS, 100% in 20 minutes with NS, and 300% in 30 minutes with NS, RL, PA, or PR. We found that all mortalities were determined within 2 hours after hemorrhage and that RL provided the best survival rate of 67% (NS 300% = 50%, PR = 40%, and PA = 30%.) After an analysis of arterial blood gas, lactate, acid-base, heart rate, and aortic pressure measurements, we conclude that RL is the superior crystalloid solution because of its decreased chloride load (compared to NS) and because of the absence of acetate or magnesium (compared to PA and PR).

Acid-Base Equilibrium↗
PubMed1986

Fluid resuscitation after an otherwise fatal hemorrhage: II. Colloid solutions.

We developed a fixed-volume porcine hemorrhage model that simulates the rapid exsanguination of combat or civilian trauma victims. In this study we compared the ability of colloid resuscitation solutions to prevent death after an otherwise lethal hemorrhage in 100 swine. The shed blood was replaced in a 1:1 ratio with either autologous whole blood (WB), untyped swine fresh frozen plasma (FFP), typed FFP, 5% human serum albumin (ALB), or normal saline (NS). Survival rate analysis indicated that WB was significantly better than FFP (untyped), ALB, or NS but not better than typed FFP. The 24-hour survival rates were: WB = 90%, typed FFP = 79%, untyped FFP = 56%, ALB = 57%, and NS = 25%. All deaths in the untyped FFP group suddenly occurred during or within 15 minutes after treatment in a recovering animal. Deaths in the ALB group steadily occurred for up to 2 1/2 hours after treatment. Analysis of hemodynamic, arterial blood gas, and acid-base data indicated that WB and FFP provided a better acid-buffering capacity in surviving animals than NS or ALB. We conclude that compatible FFP is a better resuscitation agent than ALB after an otherwise fatal hemorrhage because FFP is a better acid buffer.

Acid-Base Equilibrium↗
PubMed1985

The buffering capacity of crystalloid and colloid resuscitation solutions.

The buffering capacities of common colloid and crystalloid resuscitation solutions were compared in vitro. An equal volume of each resuscitation solution was titrated above and below its initial pH with 0.14 N sodium hydroxide or 0.11 N hydrochloric acid. The volume (+/- S.D.) of titration solution necessary to lower the pH one unit (7.1-6.1) in these solutions was less than 0.5 ml for normal saline, less than 0.5 ml for Ringer's lactate, 1.9 +/- 0.1 ml for Plasmalyte-A, 2.0 +/- 0.23 ml for Plasmalyte-R, 8.8 +/- 0.17 ml for human serum albumin (HSA), 45 +/- 2.2 ml for human fresh frozen plasma (FFP), and 50 +/- 6.6 ml for swine FFP. With the method of this in vitro study, human fresh frozen plasma was 25-50 times better as an acid buffer than the crystalloid solutions and approx. 5 times better than human serum albumin (HSA). On an equal volume basis, it was the superior resuscitation solution as a buffer, probably because of combined bicarbonate and protein content.

Animals↗