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Biomedical subjects

M H Max

Publications and source records attributed to M H Max.

At least 19 recordsLinked to original sources
PubMed1996

Laparoscopic cholecystectomy in the elderly.

BACKGROUND: Few studies have examined the results of laparoscopic cholecystectomy (LC) in the elderly. We reviewed our experience with the procedure in 194 patients age 65 and older. METHODS: A chart review was performed on patients who underwent attempted LC over a 4-year period. Age, conversion rate to open cholecystectomy (OC), length of stay, and morbidity and mortality rates were compared between elective and inpatients as well as between patients age 65-75 and patients over age 75. RESULTS: Conversion rate to OC was 10.6%. Mean length of hospital stay was 2.7 days. Morbidity and mortality rates were 18% and 1%. Elective patients experienced significantly fewer medical complications. There were no differences in complication rates between patients age 65-75 and patients over 75 years, but younger patients had a significantly shorter mean length of hospitalization. CONCLUSIONS: Elderly patients experience more complications and longer lengths of stay than the general population. However, our results compare favorably with OC series in elderly patients.

Age Factors↗
PubMed1994

Transperitoneal absorption of thermocautery-induced carbon monoxide formation during laparoscopic cholecystectomy.

Carbon dioxide pneumoperitoneum (PP) during laparoscopic cholecystectomy (LC) causes hypercapnia and acidemia. Thermocautery carbon monoxide formation during LC was studied in 15 patients. CO samples were read by electrochemical sensor as parts per million (ppm) and obtained intraperitoneally at PP, gallbladder takedown (GBTD), and exhalation. In blood, CO was measured by spectrophotometry as percentage of carboxyhemoglobin (HbCO) during anesthesia induction, at end of PP, at GBTD, and in the recovery room. Heart rate, mean arterial pressure, oxygen saturation, and end-tidal CO2 were followed prospectively. Data were analyzed by analysis of variance and Student's t test. In 35 min, thermocautery increased intraperitoneal CO from 4.7 +/- 3.8 ppm at baseline to 326 +/- 360 ppm at GBTD (p < 0.004). HbCO increased from PP to GBTD (0.7 +/- 0.6 vs. 1.2 +/- 0.7%; p < 0.01). Thermocautery produces high levels of CO intraperitoneally, which are absorbed into the circulation. Exposure time is short, which may explain the lack of hemodynamic and oxygenation changes.

Absorption↗
PubMed1988

Feeding jejunostomy: a small bowel stress test?

A review of 143 patients with 144 feeding jejunostomies was carried out. In the 129 patients in whom catheters were utilized, only 48 (45 percent) had no complications. Seventy-one patients (55 percent) suffered one or more catheter-related complications. Ten of these complications were life-threatening or fatal, including five cases of fatal small bowel necrosis. There was a significant increase in risk factors for decreased mesenteric blood flow in those patients with small bowel necrosis compared with those without this complication. In addition, the other 17 patients with abdominal distention (a manifestation of tube feeding intolerance) had a significantly increased number of risk factors for decreased mesenteric blood flow. Documented low-flow states should prompt discontinuation of tube feedings even in the patient without gastrointestinal symptoms and signs. Distention is a nonspecific but ominous finding and should prompt discontinuation of tube feedings permanently unless a reversible cause for distention is determined.

Adolescent↗
PubMed1988

Emergency department infraclavicular subclavian vein catheterization in patients with multiple injuries and burns.

We assessed the complications associated with emergency department placement of subclavian vein catheters in trauma and burn patients, reviewing the charts of all of the 441 patients admitted to the burn-trauma unit through the emergency department during 1983. Fifty-two patients (12%) had infraclavicular placement of subclavian catheters while in the emergency department. Sex, age, insertion site, blood pressure at time of insertion, indications for placement, catheters left in place, and complications were recorded. Patients with severe chest trauma or known pneumothorax or hemothorax on the ipsilateral side of line placement were excluded. The eight complications (15%) directly attributable to the procedure itself were one pneumothorax, two hematomas at the site of insertion, one knotted catheter, two misplaced catheters, and two episodes of sepsis, confirming the higher complication rates for emergency subclavian catheter insertion. Two upper extremity, 14 gauge percutaneously placed intravenous catheters are usually sufficient for resuscitation; femoral and cutdown routes offer additional sites for massive resuscitation. Subclavian catheterization is seldom needed in the emergency room. Any intravenous lines inserted in the emergency room should be changed within 24 hours to minimize infection.

Burns↗
PubMed1988

Cecal volvulus: review of 12 cases.

We reviewed the records of patients with cecal volvulus at three affiliated hospitals of Eastern Virginia Medical School to elucidate its incidence, patterns of presentation, and current methods of surgical management. We identified 109 patients in whom a discharge diagnosis of intestinal obstruction due to volvulus was made from 1966 to 1985. In 12 patients (11%) laparotomy showed the volvulus at the terminal ileum and cecum. The presenting symptoms in this group were distention in ten (83%), pain in seven (58%), obstipation or constipation in two (17%), and diarrhea in one (8%). Diagnosis was achieved by plain abdominal films in five (45%); barium enema was obtained in six patients and was diagnostic in five (83%). Two patients had delay in diagnosis with subsequent gangrene of cecum; one of them died. No deaths occurred in the group with viable bowel. Treatment was by simple detorsion without fixation in two (17%), detorsion with cecopexy in two (17%), tube cecostomy in three (25%), and ileocolectomy in three (25%). Simple detorsion was not followed by recurrence of the volvulus in any case in this series. Cecopexy for viable colon and ileocolectomy for gangrenous colon appeared to have the lowest rates of complications.

Acute Disease↗
PubMed1987

Gallbladder surgery in patients over 60: is there an increased risk?

We reviewed the records of 101 patients over the age of 60 who had exploration and cholecystectomy in 1982 at Norfolk General Hospital. There were 52 elective and 49 emergency cases. Women comprised 57.4% of the patients, and almost 50% of the patients were over the age of 70. Forty-nine percent of the cases were emergencies. All but two of the patients had cholecystectomy. The average hospital stay was 12 days for the elective group and 19 days for the urgent group. Complications extended the average hospital stay to 23 days. Although complications developed in 35 patients, only 14 had major complications that were life-threatening and/or extended the hospital stay. Of these, four were in elective cases (7%) and the remainder (21%) were in the urgent group. A major complication more than doubled the average hospital stay to 29 days. There were three deaths (3% of the entire group), all in patients who had emergency exploration, and all in patients over age 70. We advocate earlier elective cholecystectomy for patients with symptomatic cholelithiasis--before patients reach an older age, when associated systemic diseases increase their overall risk should emergency operation be necessary.

Acute Disease↗
PubMed1986

Small bowel ischemia: a consequence of feeding jejunostomy?

Continuous jejunal feeding through needle catheter jejunostomy is generally well tolerated with minimal morbidity. Small bowel ischemia or infarction has not been reported in association with jejunal feedings. We describe five patients, each of whom had grossly normal small bowel at the time of insertion of needle catheter jejunostomy. All had episodes of hypotension during continuous jejunal feedings, and subsequently had abdominal distention. Upon abdominal exploration, two patients were found to have infarction of the jejunum and three had infarction of the entire small bowel. No evidence of major vascular occlusion or mechanical obstruction was found. Patients at high risk for hypoperfusion may not tolerate jejunal feedings during such episodes. It appears possible that feeding may increase the susceptibility of the gut to hypoperfusion.

Accidents, Traffic↗
PubMed1986

Splenorrhaphy in patients with abdominal trauma.

Splenorrhaphy has become increasingly used for management of the traumatized spleen. This approach has been advocated to obviate the potential for fulminant postsplenectomy sepsis. We reviewed the records of 42 patients with penetrating or blunt trauma treated by splenectomy or splenorrhaphy at Norfolk General Hospital between 1979 and 1983. Twenty-six had splenectomy and 16 had splenorrhaphy. We evaluated age, sex, mechanism of injury, associated injuries, operative technique of splenorrhaphy, perioperative fluid requirements, and intraoperative and postoperative complications. Patients who had splenectomy had more associated injuries and more intraoperative hypotension, required more fluid replacement, and had more postoperative complications. Patients who had splenectomy were in a more unstable condition than those having splenorrhaphy; 22 of the 26 had an unsalvageable spleen. There were no complications related to splenorrhaphy. In stable patients with a potentially salvageable injured spleen, an attempt should be made to repair it before resorting to splenectomy. No added risk appears to accrue from this approach.

Abdominal Injuries↗
PubMed1986

Emergency department thoracotomy (EDT). A 26-month experience using an "agonal" protocol.

EDT can be successfully performed with the proper system in place. This includes an established thoracotomy protocol, a well-integrated EMS system, and an in-house team. Time seems to be critical, and the time between injury and EDT may be the single most important factor affecting survival other than the mechanism of injury. Cardiac penetrations, especially stab wounds, were found to have a 93 per cent survival while subdiaphragmatic penetrations had only one survivor from a group of 18 patients (5.5%). The high rate of salvage in the heart wound group probably reflects the speed of prehospital transport, though all other major series have found this group to gain the maximum benefit. No patient was successfully resuscitated from blunt injury with EDT. Three additional patients had "signs of life" restored (one pediatric blunt; two subdiaphragmatic gunshot wounds) but died of coagulopathies shortly thereafter. The experience with air ambulance patients was far too small to allow any conclusions or observations. It is felt that as the use and application of helicopters to EMS situations becomes widespread, more patients will be arriving at trauma centers with no vital signs and massive blunt injury but only moments from the accident. This special group of "dying" patients will require intense scrutiny and possibly new and inventive approaches for any hopeful salvage. Emergency thoracotomy will, no doubt, have a place as part of this. The development of a simple working protocol is of extreme importance. The protocol should be one that will allow maximum selection of patients who can benefit and elimination of those patients where EDT would be useless. The primary benefactor for EDT remains the patient sustaining a stab wound to the heart who arrives at the center shortly after injury. In other areas, such as abdominal exsanguination or severe blunt injury, further study is needed to determine what factors, prehospital and resuscitative, will improve outcome.

Abdominal Injuries↗
PubMed1986

The incidence of alcohol abuse and coagulopathy in penetrating abdominal trauma.

Preexisting coagulopathy or hepatic dysfunction is a potential problem in the alcoholic with penetrating abdominal trauma. This study reviews 36 patients with penetrating abdominal trauma to determine evidence of acute and/or chronic alcohol abuse, evidence of hepatic dysfunction, preexisting coagulopathy, pattern of blood use, and severity of injury. Sixty-four per cent of patients had detectable blood alcohol concentrations (BAC) on admission and 50% were legally intoxicated. Alcohol consumption histories were available for 24 patients, and 15 (63%) were chronic alcohol abusers. There was little evidence of hepatic dysfunction and minimal coagulopathy. There was a significant difference in the number of chronic alcohol abusers who received blood and in the amount used by any individual. There is nothing in this study to suggest this increased blood use would be lessened by including fresh frozen plasma, Vitamin K, or platelet packs in the initial resuscitation of the alcoholic patient with penetrating abdominal trauma.

Abdominal Injuries↗
PubMed1985

Carcinoma of the duodenum.

Primary duodenal carcinoma is an uncommon tumor that tends to be diagnosed late in its course because of a symptom complex compatible with many benign diseases. We reviewed the cases of five patients with duodenal adenocarcinoma treated at Norfolk General Hospital from 1973 to 1983. Periampullary tumors were excluded. The most common symptom, nausea and vomiting, was present in four patients, all of whom had microcytic anemia; in three, tests showed blood in stool specimens. The upper gastrointestinal series was suggestive of carcinoma in all patients. One of the lesions was proximal to the ampulla, while the other four were in the third and fourth portions of the duodenum. Only three of the lesions could be seen on upper GI endoscopy, and in only one of the three was the biopsy specimen positive for malignancy. At laparotomy, two patients had resectable lesions, but only segmental resection was done. Three patients had unresectable disease because of liver metastases and/or involvement of the root of the small bowel mesentery. Because delay in diagnosis of duodenal carcinoma may prevent successful resection, greater awareness of the possibility of these uncommon lesions, along with aggressive diagnostic work-up, may result in a higher percentage of cures.

Adenocarcinoma, Mucinous↗
PubMed1985

Gastric antral angiodysplasia: an unusual cause of occult gastrointestinal bleeding.

A patient with chronic occult gastrointestinal bleeding proved to have multiple gastric antral angiodysplasias and was treated with distal gastric resection. The diagnosis of this lesion is occasionally made endoscopically, since its submucosal nature makes barium contrast studies of no value. Arteriograms will also be helpful in some circumstances. Resection offers the best likelihood for permanent success.

Arteriovenous Malformations↗
PubMed1985

The use of computerized axial tomography versus peritoneal lavage in the evaluation of blunt abdominal trauma: a prospective study.

Computerized axial tomography (CAT) of the abdomen was prospectively compared with peritoneal lavage (PL) in 19 patients who sustained acute blunt abdominal trauma. All were selected carefully and were deemed stable, never having been in shock, and all required diagnostic PL. Seven patients underwent exploratory laparotomy on the basis of CAT and PL findings. There were no negative findings at laparotomy. Three significant splenic injuries, one hepatic laceration, and two hemoperitoneums were undetected by CAT. All seven cases explored were preceded by a grossly positive PL. Thus no major injury would have been missed if PL had been used alone. There were no complications of PL but one patient aspirated oral contrast medium and one patient developed hypotension during CAT. Open PL required one half the time (20.6 minutes) as CAT (47.4 minutes). The total cost of CAT was approximately eight times that of PL ($900.01 versus $116.38). In our hands, PL would seem to be significantly more sensitive with fewer false negative results than CAT of the abdomen in acute blunt abdominal trauma, a deviation from results of earlier reported series. CAT alone would have added cost, time, some risk, and very little information of use that would not be obtained by PL followed by surgery. Therefore before CAT replaces PL in the evaluation of adult patients with blunt abdominal trauma, we feel that additional prospective studies are needed to better define the accuracy and sensitivity of CAT as compared with PL with regard to intraperitoneal injuries.

Abdominal Injuries↗
PubMed1984

Breast cancer in 120 women under 35 years old. A 10-year community-wide survey.

We reviewed the records of 120 women, age 35 years or younger, with the diagnosis of breast cancer at ten hospitals in the Milwaukee metropolitan population of 1 million between 1970 and 1980. We analyzed epidemiologic factors, methods of diagnosis, treatment, and mortality. While 57 per cent of the patients sought medical attention within 6 weeks of the first symptom, 34 per cent waited longer, and physicians postponed biopsy more than 2 months in another 7 per cent. Most often, the first symptom was a painless lump (61%) and the histology was ductal carcinoma (73%). Only 61 per cent of the patients had preoperative mammography, and 52 per cent of the radiographs were interpreted as benign or negative. Estrogen receptors were obtained in only 38 per cent. At the time of presentation, only 3 per cent had evidence of distant metastases. Mastectomy with or without nodal dissection and/or pectoral muscle excision was performed on 97 per cent of the patients. Twelve per cent of the patients had or developed bilateral breast cancer. Chemotherapy, irradiation, and hormone manipulation were used alone or in combination (with or without mastectomy) in 76 per cent. Although complete 10-year survival data are not yet known, 25 per cent of the 120 patients are dead of the disease and 10% are lost to follow-up and presumed dead. These data indicate that in women age 35 years or younger with breast cancer, patient and physician delay in diagnosis has been common. Estrogen receptors and mammography have been underutilized in this patient population. However, in this community, young patients fared no worse than older women.

Adult↗
PubMed1983

Breast tumor incidence in rats after partial mammary resection.

The use of subcutaneous mastectomy in women at high risk for breast cancer is based on the assumption that surgical reduction of the tissue at risk results in a corresponding reduction in risk. To assess the validity of this assumption in an animal model, we subjected 120 female Sprague-Dawley rats to the mammary carcinogen 7,12-dimethylbenz(alpha)anthracene and a 20% fat diet. Two days later, one mammary ridge was excised in half of the animals (mastectomy group), and a midline incision was made without excision of tissue in the other half (control group). Seventy-nine rats survived dosing and operation and were observed for 77 weeks. After 15 weeks, 17 of 39 controls and seven of 40 animals with mastectomies had histologically confirmed neoplastic tumors of the breast. However, after 77 weeks, 32 of 39 controls and 35 of 40 animals in the mastectomy group had neoplastic tumors. The incidence of carcinogen-induced mammary neoplasms in rats progressed with time; whereas surgical reduction of breast tissue was followed by early reduction in neoplasias, the difference was not maintained.

9,10-Dimethyl-1,2-benzanthracene↗
PubMed1983

Recurrent gastric bezoars. A new approach to treatment and prevention.

A recurrent gastric phytobezoar was successfully dispersed using an endoscopically directed intermittent jet of dilute papain. Dissolution analysis of a retrieved bezoar fragment showed pancrelipase and Adolph's Meat Tenderizer to be effective specific solvents. The patient remained free of symptoms while on a prophylactic regimen of pancrelipase taken daily. However, when the patient discontinued his medication, the bezoar recurred. The dissolution process was successfully repeated. Selecting a reagent on the basis of demonstrated effectiveness should enhance the chance of successful dissolution of a phytobezoar, whereas prophylactic doses of the reagent may prevent its recurrence.

Adult↗
PubMed1983

Early and late complications after thyroid operations.

The cases of 387 patients who had 407 operations for thyroid disease between 1958 and 1982 at a university-affiliated city-county hospital were evaluated to assess the morbidity and mortality associated with thyroid operation. A mortality of 0.7% was found, owing to coexisting systemic disease, advanced patient age, and delayed treatment. Recurrent laryngeal nerve damage was rare (0.6%). Permanent hypoparathyroidism appeared in 0.9%, probably related to disrupted blood supply rather than tissue removal. Of those patients who had subtotal thyroidectomy and follow-up of six years or more, 15.8% had hypothyroidism, a rate substantially lower than that following radioactive iodine ablation for Graves' disease. This study indicates that operative procedures on the thyroid can be done with acceptable morbidity and mortality.

Adolescent↗