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M B Farnell

Publications and source records attributed to M B Farnell.

At least 19 recordsLinked to original sources
PubMed1999

Long-term results of biliary reconstruction after laparoscopic bile duct injuries.

HYPOTHESIS: The Hepp-Couinaud approach to biliary enteric reconstruction for laparoscopic bile duct injuries provides a durable, long-term result in most patients. DESIGN: Retrospective study of patients who underwent operative repair of laparoscopic bile duct injuries from January 1990 through December 1997. SETTING: Academic tertiary referral center. MAIN OUTCOME MEASURES: Outcome was assessed using a grading system based on clinical symptoms, liver function tests, and need for reintervention for anastomotic stricture. The Kaplan-Meier method was employed to estimate stricture-free survival. RESULTS: Fifty-nine consecutive patients underwent operative repair of the following laparoscopic bile duct injuries (Strasberg classification): B: n = 2 (3%), C: n = 1 (1%), D: n= 2 (3%), E1: n= 5 (8%), E2: n= 16 (27%), E3: n= 25 (42%), E4: n = 5 (8%), and E5: n = 3 (5%). Forty-seven patients (80%) had 1 or more interventions prior to the index repair. The extrahepatic left bile duct (Hepp-Couinaud approach) was used in 46 of 53 patients who underwent a Roux-en-Y hepaticojejunostomy. Follow-up (mean+/-SEM, 3.7+/-0.3 years) was complete in 54 of the 57 patients still alive. Five patients developed subsequent anastomotic strictures and were treated with percutaneous transhepatic dilation (n = 3), endoscopic dilation (n = 1), and operative revision (n= 1). Excellent to good long-term results were achieved in the remaining 49 patients (91%). Life-table analysis yielded 95% and 88% chances of stricture-free survival at 2 and 5 years, respectively. CONCLUSIONS: Complex iatrogenic proximal bile duct injuries and strictures are amenable to operative repair using the extrahepatic left bile duct. The Hepp-Couinaud approach offers a durable result in more than 90% of patients, even after previous interventions have failed.

Bile Ducts↗
PubMed1996

Risk of recurrent biliary tract disease after cholecystectomy in patients with duodenal diverticula.

OBJECTIVE: To determine if the presence of duodenal diverticula predisposes to the development of common bile duct stones. DESIGN: Cohort study; median follow-up, 10.0 years (25th and 75th percentiles, 5.2 and 16.1 years, respectively). SETTING: Tertiary care center. PATIENTS: One hundred fifty-seven patients with radiologically diagnosed duodenal diverticula who had undergone cholecystectomy from 1950 through 1987 and were asymptomatic at the initiation of follow-up. MAIN OUTCOME MEASURES: All patients were followed up for evidence of recurrent biliary tract disease to the following end points: (1) evidence of choledocholithiasis demonstrated by radiologic surgical, or biochemical means and (2) clinical or biochemical evidence of biliary pancreatitis. RESULTS: Of the 157 patients in the study cohort, 13 patients were categorized as having had recurrent biliary tract disease. Using the Kaplan-Meier survivorship method, the cumulative probabilities of recurrent biliary tract disease in patients with radiologically diagnosed duodenal diverticula were 3.6% at 5 years (95% confidence interval, 0.5-6.9), 5.5% at 10 years (95% confidence interval, 1.5-9.4), and 10.2% at 15 years (95% confidence interval, 3.8-16.7). Age, common bile duct exploration and choledochotomy, and the presence of common bile duct dilatation were not found to be significantly associated with recurrence based on a univariate analysis of risk factors by means of the log-rank statistic. CONCLUSIONS: For patients with radiologically diagnosed, second-portion duodenal diverticula, the risk of developing recurrent bile duct stones after cholecystectomy is lower than has been suggested in previous studies. In the absence of concurrent choledocholithiasis, sphincterotomy or biliary bypass at the time of cholecystectomy seems unwarranted.

Adult↗
PubMed1995

Preoperative highly selective catheter localization of occult small-intestinal hemorrhage with methylene blue dye.

In patients with occult lower gastrointestinal bleeding, locating of the source of the hemorrhage can be quite difficult. While multiple diagnostic tests may confirm a small bowel source of bleeding, precise localization allowing a directed, conservative surgical resection may be problematic. We describe three patients each of whom presented with hemorrhage from the small intestine. The preoperative use of highly selective angiographic catheter placement combined with intraoperative methylene blue dye injection allowed us to precisely locate the source of hemorrhage and to resect a conservative length of small intestine. This technique has been successful in the three patients herein, and we believe that it should be included in the options available to the surgeon.

Adult↗
PubMed1995

Selective operative cholangiography. Appropriate management for laparoscopic cholecystectomy.

OBJECTIVE: To evaluate the results of selective intraoperative cholangiography (IOC) in patients undergoing laparoscopic cholecystectomy. DESIGN: Retrospective study. SETTING: Mayo Clinic, Rochester, Minn, from 1990 to 1991. PATIENTS: Five hundred forty-two patients underwent attempted laparoscopic cholecystectomy. Excluding 28 (5.2%) who underwent conversion to laparotomy and 19 (3.5%) who did not respond to a follow-up questionnaire, there were 495 respondents (mean follow-up, 25 months). MAIN OUTCOME MEASURE: Incidence and management of choledocholithiasis, extrahepatic bile duct injuries, and other findings potentially affected by IOC. RESULTS: Twenty patients underwent preoperative endoscopic retrograde cholangiopancreatography for suspected common bile duct abnormalities, and 10 had common bile duct stones removed. Nearly a third (n = 161 [32.5%]) of the patients underwent IOC for laboratory, historical, or operative findings or for training purposes. Common bile duct stones were discovered on IOC in five patients (3.1%), three of whom were treated successfully with postoperative endoscopic therapy; the two others had normal findings on endoscopic retrograde cholangiopancreatography (false-positive results of IOC). In three other patients in whom IOC was unsuccessful or incomplete, symptomatic common bile duct stones developed. Two patients were treated with endoscopic techniques, and one required open common bile duct exploration. Among the 334 patients who did not undergo IOC, symptoms suggestive of retained stones developed in eight (2.4%) (all within 2 months of surgery; mean, 18 days), but stones were found at endoscopy retrograde cholangiopancreatography in only four patients. Two had preoperative criteria for performing IOC. In only three patients (0.6%) from the study population would symptomatic retained common bile duct stones have developed with selective IOC and routinely successful IOC. No common bile duct injuries occurred. CONCLUSIONS: Selective IOC during laparoscopic cholecystectomy is a safe practice when the ductal anatomy is clearly defined and there is no laboratory or clinical evidence of common bile duct abnormalities. Symptomatic retained common bile duct stones will be infrequent, and bile duct injuries will be rare when IOC is performed for the appropriate indications. These data do not support the need for routine IOC, although this procedure is an essential tool for the laparoscopic surgeon.

Adult↗
PubMed1995

Benign biliary strictures: repair and outcome with a contemporary approach.

BACKGROUND: The Hepp-Couinaud technique is an innovative approach for repair of proximal biliary strictures. We have used this method selectively for bile duct reconstruction since 1982. Our aim was to analyze our experience with the surgical repair of benign biliary strictures in the decade since the Hepp-Couinaud technique has become an integral component of our surgical management strategy. METHODS: Seventy-two patients undergoing surgical repair of benign biliary stricture between 1983 and 1992 were reviewed retrospectively. A grading system on clinical symptoms, results of liver function studies, and need for reintervention was used to assess outcome. RESULTS: For the 27 patients with noniatrogenic strictures, followed up a mean of 3.9 years, excellent or good results (grade A or B) were obtained in 88.9%. For the 45 patients with iatrogenic strictures, followed up a mean of 4.6 years, 86.7% were categorized as grade A or B. The cumulative probability of anastomotic failure was significantly less for the 21 patients in whom the Hepp-Couinaud method was used when compared with the 24 patients in whom it was not (p = 0.032). Outcome was not influenced by age, time delay from injury to reconstruction, preoperative stenting, the number of previous repairs, or the duration of postoperative stenting. CONCLUSIONS: Surgical reconstruction affords excellent or good results for the vast majority of patients with benign biliary strictures. For proximal iatrogenic strictures superior anastomotic durability is achieved with the Hepp-Couinaud technique.

Adult↗
PubMed1995

Epithelioid gastric stromal tumors (leiomyoblastomas): a study of fifty-five cases.

BACKGROUND: Epithelioid gastric stromal tumors form a distinct histologic subset of gastric tumors whose malignant potential and prognosis are controversial. METHODS: Fifty-five patients with epithelioid gastric stromal tumors accounted for 11.5% of patients undergoing definitive operations for gastric stromal tumors from 1960 to 1986. Medical records and pathology slides were reviewed, and immunohistochemical staining and flow cytometry were performed. The Kaplan-Meier method was used to estimate survival. Survival curves were compared with log-rank tests and Cox proportional hazards model. RESULTS: Of the 55 tumors, 40 were benign and 15 (27%) were malignant. Mean follow-up was 10.5 years. Ten patients died of their disease. No patient with a benign tumor had recurrence of metastasis, but all patients with high-grade malignancy had died of disease within 3 years after diagnosis. Seventy-five percent of proximal tumors were malignant. Extent of resection had no impact on survival (p = 0.5). CONCLUSIONS: The best determinant of tumor behavior was histologic grade. Twenty-seven percent of patients had malignant tumors, and 67% of these died of disease. Other significant prognostic factors included a mitotic count greater than 5/10 high-power fields, size larger than 6 cm, aneuploidy, and higher S-phase fraction (p < 0.01). Proximal lesions were more likely to be malignant. Extent of surgical treatment had no effect on survival.

Adolescent↗
PubMed1995

An argument against routine percutaneous biopsy, ERCP, or biliary stent placement in patients with clinically resectable periampullary masses: a surgical perspective.

Improve resolution of computed tomography (CT) and ultrasonography allows us to visualize the proximal extent of biliary obstruction and the presence of a periampullary mass in most patients with malignant extrahepatic biliary obstruction. Our purpose in this report is to challenge the need for preoperative percutaneous biopsy, endoscopic retrograde cholangiopancreatography, or preoperative placement of a biliary endoprosthesis in the good-risk patient in whom the imaging procedure clearly defines a periampullary mass and the proximal extent (hepatic extent) of biliary obstruction. We recently managed three patients in whom one of these invasive procedures led to a complication that delayed, prevented, or complicated appropriate operative resection of a pancreatic neoplasm. Because a negative percutaneous biopsy, cholangiographic imaging of a dilated bile/pancreatic duct clearly seen on CT or ultrasonography, or short-term preoperative biliary decompression does not alter the decision for operative exploration and may cause complications, we argue against their use in the good-risk patient with both extrahepatic biliary obstruction and a periampullary pancreatic mass well delineated on noninvasive imaging.

Aged↗
PubMed1994

Multisystem geriatric trauma.

PURPOSE: To analyze the demographics, hospital course, functional outcome, and reimbursement for elderly patients sustaining multisystem trauma. METHODS: The Trauma Registry was searched for patients > or = 65 years old with an Injury Severity Score (ISS) > or = 10 admitted with multisystem trauma from January 1991 through December 1991. Hospital data were obtained from the Trauma Registry; reimbursement data from the business office; and complete follow-up (mean, 12 months) data by telephone survey for all patients. RESULTS: Of the 1931 trauma patients admitted during the study period, 601 (31%) were > or = 65 years old and 94 (5%) met the study criteria. Of these 94 patients, 52 were women and 42 were men; their mean age was 79 years (range, 65-100). Falls (59%) and motor vehicle crashes (36%) were the predominant causes of injury; closed head injury (CHI) and fractures were the most frequent injuries. The mean ISS was 18 (range, 10-57), and hospital stay averaged 10 days. Intensive care unit admission was necessary for 37%, and 38% required surgical intervention. Factors associated with mortality included previous myocardial infarction, chronic renal insufficiency, ventilatory or inotropic support (or both), shock (systolic BP < or = 90 mm Hg) at admission, bradycardia (HR < or = 60 bpm) at admission, and severe CHI (Glasgow Coma Scale score < or = 8). Mortality was 23% (22 of the 94 patients); three quarters of the deaths occurred in the first 24 hours--most from severe CHI. At discharge, 53% of patients (38 of 72) went home and 36% (26 of 72) went to nursing homes. At a mean follow-up of 12 months, an additional seven patients had died, and three quarters of the patients were at home with an independent functional status. The percentage of reimbursement for care was two thirds of cost. CONCLUSIONS: Mortality rates are high for elderly patients who sustain multisystem trauma. Most deaths occur within the first 24 hours, and most injuries are severe CHIs. More than half of survivors are discharged home, and most are independent at long-term follow-up. Reimbursement is not commensurate with the functional outcome achieved and the care provided.

Aged↗
PubMed1994

Nonmeckelian jejunal or ileal diverticulosis: an analysis of 112 cases.

BACKGROUND: Incidentally found asymptomatic disease, chronic pain or malabsorption, emergent disease with complications are the three distinct modes of presentation of nonmeckelian jejunal or ileal diverticulosis (JID). We analyzed our experience with each of these three subsets of cases to determine both the role of operative intervention and an overall management strategy. METHODS: Retrospective analysis was done of 112 clinically diagnosed cases of nonmeckelian JID between 1975 and 1990. RESULTS: JID was an incidental finding in 47 patients (42%), and 82% of those who were followed up for a mean of 4.8 years remained asymptomatic. Forty-five patients (40%) had malabsorption or chronic pain, and only 46% of those who were followed up for a mean of 6.5 years were cured with conservative therapy. Of the 20 patients (18%) who had acute complications, 11 (10%) required operation, which was associated with minimal morbidity and one death. Ninety percent remained asymptomatic for a mean of 3.9 years. CONCLUSIONS: Incidentally found JID is usually asymptomatic and should be observed. Resection for complicated JID is safe and effective. Although malabsorption or chronic pain should be treated medically initially, the significant incidence of failure warrants further study of the role of resection in this group.

Acute Disease↗
PubMed1993

Outcomes after curative resections of cholangiocarcinoma.

OBJECTIVES: To elucidate the clinical and pathologic features of extrahepatic cholangiocarcinomas and to identify prognostic variables in patients treated surgically. DESIGN: Retrospective review of clinical records of patients undergoing surgical exploration for cholangiocarcinoma, with univariate and multivariate analyses of the clinical and pathologic factors that influenced patient survival. SETTING: Mayo Clinic, Rochester, Minn. STUDY PARTICIPANTS: One hundred seventy-one patients undergoing operative intervention for diagnostic, palliative, or curative reasons between 1976 and 1985. Follow-up was complete until death or for a minimum of 5 years for surviving patients. INTERVENTION: A curative surgical resection was performed in 29% of patients, while the remainder underwent tumor biopsy or a palliative procedure. MAIN OUTCOME MEASURE: Patient survival following operative treatment. RESULTS: The operative mortality in this patient cohort was 5% and median survival was 13 months. Overall 5-year survival was 16%, with 44% of patients having a curative resection still alive at 5 years. Using univariate analysis, curative resection, tumor stage, Eastern Cooperative Oncology Group performance status, total bilirubin concentration, lymph node status, liver invasion, tumor morphology, tumor grade, and site of tumor origin were significant determinants of prognosis. Using the Cox proportional hazards model for multivariate analysis, curative resection, Eastern Cooperative Oncology Group performance status, total bilirubin concentration, and tumor grade were the only variables predictive of patient outcome. A curative resection of a proximal cholangiocarcinoma had a similar chance of providing long-term survival as a curative distal ductal resection. CONCLUSIONS: Although the tumor extent and the patient's overall health will affect outcome, curative resection for cholangiocarcinoma at all sites should be undertaken since this treatment offers the best chance for long-term survival.

Adenoma, Bile Duct↗
PubMed1993

Spectrum and management of major complications of laparoscopic cholecystectomy.

Laparoscopic cholecystectomy has become the most prevalent method of treating uncomplicated, symptomatic cholelithiasis in the United States and elsewhere. As experience with this procedure grows, certain pitfalls are becoming apparent. Since October 1990, we have treated 22 patients for major injuries incurred during laparoscopic cholecystectomy, including 15 women and 7 men (range: 23 to 85 years). One patient had previous upper abdominal surgery; no other patient had any relative contraindication to laparoscopic surgery. The most frequent site of injury (19 patients) was the extrahepatic biliary tract. There was one fatal duodenal perforation. All but two patients whose injuries went unrecognized at laparoscopy were symptomatic during the immediate postoperative period. The biliary injuries included complete transection of the common hepatic or common bile duct in 10 patients, complete ductal occlusion in 3, a cystic duct stump leak in 2, and a partially retained gallbladder with a contained intraperitoneal bile leak in 2. The site and extent of biliary injuries were delineated with transhepatic or endoscopic retrograde cholangiography. Reconstruction or repair of the biliary tract was accomplished with Roux-en-Y hepaticojejunostomy or cholangiojejunostomy in 11 and 1 patients, respectively, completion cholecystectomy in 2, and temporary transhepatic stenting, primary choledochocholedochostomy, and primary choledochorrhaphy over a T-tube in 1 patient each. One patient with a cystic duct stump leak was managed successfully with endoscopic sphincterotomy, whereas another required operative ligation. Laparoscopic injuries during cholecystectomy can lead to serious morbidity and mortality, thus emphasizing the need for adequate training and credentialing for surgeons and for a heightened clinical awareness of the potential complications, their long-term sequelae, and how to avoid them.

Adult↗
PubMed1993

Nutritional support of critically ill patients.

Severe depletion of body protein stores can result from prolonged starvation or from hormonal and cytokine-mediated effects during critical illness. Recent advances in the understanding of cytokine actions have substantially refined the interpretation of the nutritional assessment of critically ill patients. In addition, the design of nutritional programs for hospitalized patients has changed considerably during the past decade. Although nutritional support of critically ill patients will not lead to positive nitrogen balance, nutrition can increase protein synthesis, enhance immune function, and beneficially modify the body's response to an illness.

Critical Illness↗
PubMed1992

Prevention of infection in critically ill patients by selective decontamination of the digestive tract.

OBJECTIVE: To determine whether selective decontamination of the digestive tract using oral and nonabsorbable antimicrobial agents and parenteral cefotaxime prevents infection in critically ill patients. DESIGN: Randomized, controlled trial without blinding. SETTING: Surgical trauma and medical intensive care units in a tertiary referral hospital. PATIENTS: One hundred fifty patients admitted to surgical trauma and medical intensive care units during a 3-year interval, whose condition suggested a prolonged stay (greater than 3 days). INTERVENTION: Patients were randomly allocated to an experimental group (n = 75) that received cefotaxime, 1 g intravenously every 8 hours for the first 3 days only, and oral, nonabsorbable antibiotics (gentamicin, polymyxin, and nystatin by oral paste and oral liquid) for the entire stay in the intensive care unit. Control patients (n = 75) received usual care. MEASUREMENTS: The number of infections, total hospital days, and deaths, as well as the number of days in intensive care unit, were recorded. RESULTS: Control patients experienced more infections (36 compared with 12, P = 0.04), including bacteremias (14 compared with 4, P = 0.05) and pulmonary infections (14 compared with 4, P = 0.03). Although total hospital days, days in intensive care, and the overall death rate all were lower in the treatment group, these differences were not statistically significant. Clinically important complications of selective decontamination of the digestive tract were not encountered. CONCLUSIONS: Selective decontamination of the digestive tract decreases subsequent infection rates, especially by gram-negative bacilli, in selected patients during long-term stays in the intensive care unit.

Administration, Oral↗
PubMed1992

Laparoscopic cholecystectomy: operative technique.

Laparoscopic cholecystectomy has become the routine procedure for most patients with symptomatic cholelithiasis. At our institution, a two-surgeon, four-cannula technique is used. In almost all patients, a pneumoperitoneum can be established with use of a closed technique. Adherence to standard operative principles and careful attention to details in the laparoscopic technique will routinely result in the safe completion of laparoscopic cholecystectomy. Cautery provides excellent hemostasis during dissection of the gallbladder from its attachments. Cholangiography through the gallbladder or the cystic duct is easily performed in selected patients. Minimal perioperative care is necessary for patients who undergo laparoscopic cholecystectomy, and the hospitalization time is usually less than 24 hours.

Cautery↗
PubMed1992

Laparoscopic cholecystectomy: early Mayo Clinic experience.

Prospective data and follow-up information were collected on the initial 200 patients who underwent laparoscopic cholecystectomy at the Mayo Clinic. The operation was completed laparoscopically in all but five patients, who required conversion to laparotomy because of dense scarring or stones in the common bile duct. The median surgical time was 85 minutes. The major postoperative complications were retained stones in the common bile duct (in seven patients), intraperitoneal hemorrhage that necessitated transfusion (in two patients), and intra-abdominal abscess and pulmonary infection (in one patient each). The median hospital stay was 1 day (range, 0 to 8 days), and the median times to full activity and normal employment were 8 days and 12 days, respectively. Laparoscopic cholecystectomy is associated with a low frequency of complications in most patients with symptomatic gallstones and allows a rapid return to normal activity. Currently, laparoscopic cholecystectomy is the treatment of choice for most patients with symptomatic cholelithiasis.

Academic Medical Centers↗
PubMed1992

Spontaneous rupture of the spleen due to infectious mononucleosis.

Spontaneous splenic rupture is an extremely rare but life-threatening complication of infectious mononucleosis in young adults. Although splenectomy remains effective treatment, reports of successful nonoperative management have challenged the time-honored approach of emergent laparotomy. On retrospective analysis of our institutional experience with 8,116 patients who had this disease during a 40-year period, we found 5 substantiated cases of atraumatic splenic rupture due to infectious mononucleosis. Four additional cases of suspected splenic rupture were noted. All nine patients were hospitalized and treated (seven underwent splenectomy and two were treated with supportive measures only), and they remain alive and well. In patients with infectious mononucleosis suspected of having rupture of the spleen, a rapid but thorough assessment and prompt implementation of appropriate management should minimize the associated morbidity and mortality. On the basis of review of the medical literature and careful scrutiny of our own experience, we advocate emergent splenectomy for spontaneous splenic rupture in patients with infectious mononucleosis.

Adolescent↗