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Biomedical subjects

P J Harbrecht

Publications and source records attributed to P J Harbrecht.

At least 19 recordsLinked to original sources
PubMed1986

Leaks and obstruction after gastric resection.

Postoperative gastric retention may be minimized by avoiding the use of the Billroth I reconstruction when a large duodenal ulcer must be retained. Postoperative gastric retention is more likely to remit with conservative therapy if the procedure was a Billroth I reconstruction with a vagotomy. In other instances where there is difficulty in gastric emptying, a mechanical cause should be strongly suspected. The optimum duration of a conservative trial with suction for postoperative gastric retention may be debatable, and contrast radiography or endoscopy may be helpful; however, patience and suction are not long-term substitutes for a needed operation.

Adult↗
PubMed1984

Early urgent relaparotomy.

We analyzed the indications for and implications of reoperation in 113 patients who required early urgent relaparotomy. Infection with intact organs was the most common indication, causing the most diagnostic difficulties, and presenting the most varied findings. Suture-line leaks and dehiscence were next in frequency. Bleeding caused the earliest relaparotomies and obstruction, the latest. In seven patients a technical error at the primary laparotomy was identified, and in 56 patients an error of some sort was presumed. High-mortality categories were identified, including the elderly, who were particularly susceptible if bleeding or after an emergency primary laparotomy. An aggressive policy of reoperation resulted in 59 survivors and seems to be the only practical approach in the treatment of these usually desperately ill patients.

Aged↗
PubMed1984

The impact of demographic trends on hospital surgical care.

The projected increase in numbers and percentages of elderly people has great potential impact on health services generally. Only rarely, however, has the impact of age of patients on a surgical service been quantitated. Two hundred fifty-five consecutive laparotomies performed in men older than 65 years of age were compared with 174 consecutive laparotomies in men younger than 65 years of age, all from a Veterans Administration Medical Center experience. Morbid factors, including mortality, increased with age with the greatest increments over the age of 75 years and especially over the age of 85 years. An intensity-of-care index was devised; the intensity-of-care ratios progressively increased with age. Unless there are significant technical advances, future surgical results will not be as good as they are at present, since the patient composition will be less favorable. Any estimates of the costs of surgical care in the future must include the projected age of patients as a major factor.

Abdomen↗
PubMed1983

Iatrogenic ureteral injury. Options in management.

Twenty-five patients sustained 27 iatrogenic ureteral injuries during various operative procedures. Injuries were managed by ureteroureterostomy in 11 injuries, ureteroneocystostomy in 11, nephrectomy in two, ureteral stent in one, cutaneous ureterostomy in one, and reimplantation into an ileal conduit in one. Four of 25 patients died, three as a result of the failure of ureteral repair and intra-abdominal sepsis. Short-term failure of repair occurred in five patients; long-term failure occurred in three. All patients with injuries missed during the primary operation had poor results of ureteral reconstruction. Immediate recognition of accidental ureteral injury provides optimum results. Injuries within 4 cm of the ureterovesical junction are managed by ureteroneocystostomy; injuries greater than 4 cm, by ureteroureterostomy. Crush injuries require immediate placement of a ureteral stent. Prior pelvic radiotherapy or intra-abdominal infection should preclude any attempt at primary reconstruction.

Adult↗
PubMed1983

Associated lung lesions in patients with primary head and neck carcinoma.

From a 9-year Veterans Administration Medical Center experience, 34 patients were identified who had synchronous or metachronous pulmonary lesions in association with primary head-neck carcinoma. Evaluation of the pulmonary lesions included bronchoscopy, mediastinoscopy, and thoracotomy. Lung lesions were felt to be metastatic lesions from head and neck primary in 12 patients, primary lung carcinoma in 20 patients, and metastases from subdiaphragmatic primary neoplasms in two patients. This study demonstrates that head-neck carcinoma may spread to the lung but that associated lung lesions are most commonly second primary neoplasms.

Adult↗
PubMed1983

Role of infection in increased mortality associated with age in laparotomy.

Mortality in patients undergoing laparotomy increases with age of the patient. Concomitantly other morbid perioperative factors also are increased, including number and grade of associated system diseases, preoperative infections, severity of disease, emergency operations, post-operative infectious and noninfectious complications, organ failures, and forced secondary operations. All these and other factors may play a role in mortality but two patterns of death are predominant. Some elderly patients present in shock from blood loss or with overwhelming sepsis and die at operation or shortly thereafter. The majority of others who die have intra-abdominal infections preoperatively or they develop infectious complications and these initiate or perpetuate a train of morbid events that prove fatal after days or weeks of intensive supportive therapy. The inability of elderly patients to avoid or to recover from infection appears to be the most common causative factor in increased mortality with age in laparotomy patients.

Age Factors↗
PubMed1982

Applications of choledochoduodenostomy in biliary tract obstruction.

Forty-three patients each underwent choledochoduodenostomy for distal biliary obstruction. The results were satisfactory for those patients with benign obstructions. Choledochoduodenostomy was complicated by recurrent biliary obstruction in five of 19 patients with obstructing neoplasms, and is generally a poor choice in those circumstances. Choledochoduodenostomy is a useful procedure for patients with benign distal biliary tract obstructions, particularly when dealing with elderly, poor-risk patients.

Adenocarcinoma↗
PubMed1981

Systemic prophylactic antibiotics: need the 'cost' be so high?

To assess compliance with accepted principles, the use of prophylaxis with systemic antibiotics in selected specialty procedures was examined. The operations reviewed were aortofemoral bypass, pulmonary resections, open-hip procedures, and head-neck cancer procedures that involve the oropharyngeal cavity. Of all patients, 74% received antibiotics preoperatively and 79% received prophylaxis with antibiotics longer than 24 hours postoperatively. Evaluated against the criteria of preoperative initiation and limited postoperative administration (less than 24 hours) only 10% of the patients received appropriate prophylaxis. A 3% incidence of drug-associated complications was identified; each patient with complications had received antibiotics for a prolonged time postoperatively. Reduction in the length of postoperative prophylaxis with systemic antibiotics will reduce (1) the number of drug-associated complications, (2) selection pressures on the hospital microbial population, and (3) needless expense in hospitalized patients.

Anti-Bacterial Agents↗
PubMed1981

Empyema of the gallbladder: a complication in the natural history of acute cholecystitis.

Empyema of the gallbladder was identified in 34 patients. Patients undergoing early operation without attempts at nonoperative treatment had less infectious morbidity and mortality. Delayed operative intervention, extrabiliary abscess, perforation of the gallbladder and common duct exploration are factors that contribute to increased risks in these patients.

Abscess↗
PubMed1981

Surgery in elderly patients.

Operations on patients over 65 years old are increasing steadily in number and complexity. Demographic trends indicate that future increases will be even greater. We reviewed patients having operations of diverse type and magnitude to determine results, with emphasis on the influence of age. Increased risk in older persons was most evident in emergency situations where the frequently associated systemic diseases and the inevitable diminution in organ functional reserves could not be adequately treated or compensated. Appropriate management of elderly patients through surgical procedures requires knowledge of the peculiarities in their responses to disease, medications, and other stimuli.

Aged↗
PubMed1981

Gangrene of the gallbladder: a complication of acute cholecystitis.

Eighteen cases of gangrenous cholecystitis were reviewed to better define causes of morbidity and mortality. All patients in the series presented with signs and symptoms of acute cholecystitis. Cholecystectomy was done as an emergency procedure in 12 patients, while in six patients cholecystectomy followed a failure of nonoperative therapy. Gangrenous cholecystitis in this series was commonly associated with empyema and perforation of the gallbladder. Three of six patients having cholecystectomy after failure of nonoperative treatment died, while only one of 12 patients with immediate cholecystectomy died. This series illustrates that gangrenous cholecystitis usually presents with a clinical picture identical to that of acute cholecystitis. Early operation in the natural history of acute cholecystitis should reduce the frequency as well as the morbidity and mortality of gangrenous cholecystitis.

Acute Disease↗
PubMed1981

A prospective study of carotid endarterectomy with and without shunt.

The extent of cerebral protection necessary during carotid endarterectomy for ischemia is controversial. In 147 carotid endarterectomies, carotid backflow was estimated and, in later years, these clinical impressions were correlated with stump pressure. These estimates or values, modified particularly in early years by the extent of contralateral disease and (inversely) of ipsilateral occlusion, were used to determine the need for a shunt at the time of carotid clamping. Only 32 shunts were used, 12 because of poor back bleeding and 20 because of stump pressure below 50 mmHg. The patients who received shunts had no mortality or neurologic deficits. In 30 patients excluded by adequate stump pressure there was only a single minor and temporary monoparesis. In 85 patients excluded by apparently good back bleeding, there were two deaths (one due to stroke), a permanent 10 per cent neurologic deficit, and two postoperative thromboses salvageable by reoperation. Routine shunting would probably have prevented only the temporary monoparesis and the 10 per cent neurologic deficit. Meticulous technique and selective use of a shunt should give satisfactory results.

Adult↗
PubMed1980

Clinical considerations in unusual colonic obstructions.

Colonic obstructions of uncommon cause may present challenging diagnostic problems that require prompt and correct treatment. Fifty such patients were studied and illustrate the problems that may be encountered. Clinical observations of importance include the need to distinguish a prostatic cancer obstructing the rectum, the mimicking of inoperable cancer by various benign processes, the need to decompress an enlarging cecum even in paralytic ileus, and the occasional inadequacy of sigmoidectomy as the elective treatment of sigmoid volvulus.

Adenocarcinoma↗
PubMed1980

Pseudoaneurysms and related complications of aortic bypass grafts.

During a recent five-year period 14 patients had pseudoaneurysms as late complications of aortic bifurcation grafts. Severe atherosclerosis had been present at the time of the aortic grafts, and subsequent progression of arterial disease appeared to be the usual cause of the pseudoaneurysms which occurred from two to 14 years later. Nineteen of the 23 pseudoaneurysms in the 14 patients were in the groin. Excision and interposition graft usually worked well. Eleven patients had early benefit. Two early failures were due to infection. The long-term results correlated with success in obtaining adequate arterial outflow. Rupture of pseudoaneurysms, concomitant thrombosis, other complications, and diagnostic errors also caused operative problems and influenced results.

Adult↗
PubMed1979

Recurrence of volvulus after sigmoidectomy.

Three patients had recurrences of left-sided colonic volvulus after allegedly total resections of redundant sigmoid loops. All three patients had chronic, acquired megacolon. Other instances of late recurrence of volvulus after sigmoidectomy are documented in the literature. Sigmoidectomy may be an inadequate operation for sigmoid volvulus in younger patients and/or in patients with severe chronic megacolon. The decision to perform an interval operation and the selection of the type of operation must take this into account.

Colon, Sigmoid↗
PubMed1979

Results of corrective surgery for alkaline reflux gastritis.

Reflux alkaline gastritis and esophagitis have been incriminated as a source of symptoms in achlorhydric patients afer operation for duodenal ulcer. Documentation of such pathologic findings has increased due to widespread use of fiberoptic endoscopy. As reported in the literature, results of remedial operations have ranged from encouraging to excellent, and evaluations have been uniformly laudatory. Correlation of the extent of symptoms and of pathologic findings has been difficult, and our results have not been as good as those reported in the literature. During a six-year period, the diagnosis of bile reflux gastritis in 13 patients was based on a characteristic symptom complex, endoscopic appearance, and histopathologic confirmation. Either a Roux-en-Y gastrojejunostomy or a Tanner-Roux 19 was the corrective procedure. There was complete relief of symptoms in five patients (38%) and partial relief in four, but no apparent relief in four others. In at least three of the patients, chronic gastritis and/or esophagitis have persisted and have not improved despite biliary diversion. Tabulation of the results of 13 remedial operations for reflux alkaline gastritis disclosed that copmlete relief of symptoms was achieved in 50% of those who had the Roux-en-Y and in 20% of those who had the Tanner 19 procedure. Based on our findings, we recommend a cautious approach to the surgical management of alkaline gastritis.

Adult↗