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Biomedical subjects

R B Adkins

Publications and source records attributed to R B Adkins.

At least 19 recordsLinked to original sources
PubMed2000

Embryology, anatomy, and surgical applications of the extrahepatic biliary system.

As technology has improved and the ability to apply this technology in the surgical arena has grown, surgeons have been able to perform more sophisticated operative procedures. Hepatobiliary surgeons are now able to use laparoscopy, immunosuppressive drugs, and technical advances in cryosurgery to accomplish magnificent results. The success and safety of laparoscopic cholecystectomy, orthotopic liver transplantation, and trisegmentectomy for hepatic tumors depend on a high regard for and an accurate knowledge of the anatomy and some of the common embryologic anomalies of the biliary tree. The blood supply, ductal variations, and gallbladder anatomy of this area are often the source of major challenge to unprepared and unaware surgeons. The authors have attempted to stimulate an interest in, a respect for, and perhaps some desire to learn more about the important and fascinating anatomy of this region.

Bile Duct Diseases↗
PubMed1997

General surgical clinical pathways: an introduction.

With increasing pressures to reduce the cost of health care, protocols and practice guidelines are being developed to streamline the practice of medicine. Many of these guidelines have been developed by health care workers who are not involved in the daily care of patients and who do not have clinical expertise in the specific diseases. The Southeastern Surgical Congress appointed a committee to develop clinical pathways for common surgical diseases. These clinical pathways have been developed by practicing surgeons with expertise in common surgical diseases and reviewed for their applicability by other surgeons with clinical expertise. The types of guidelines are reviewed and the need for guidelines are discussed. This paper presents the purpose, development, essential elements, and the dissemination and implementation of clinical pathways for common surgical diseases. It is critical that surgeons and surgical organizations participate in developing clinical guidelines and clinical pathways.

Critical Pathways↗
PubMed1993

Preliminary results with neoadjuvant therapy and resection for esophageal carcinoma.

Between December 1988 and August 1992, 68 patients with adenocarcinoma (n = 39) and squamous carcinoma (n = 29) of the esophagus were entered prospectively in a treatment protocol to receive two cycles of cisplatin, 5-fluorouracil, etoposide, leucovorin, and 3,000 cGy of radiation to the involved esophagus and adjacent mediastinum, followed by resection. There were four deaths during chemotherapy, and 7 patients had a decline in condition or were denied operation. Fifty-six patients have come to operation, and 1 awaits resection. Twenty-two patients had transhiatal esophagectomy and 29 patients had esophagogastrostomy with a combined abdominal and right thoracic approach. Five patients did not undergo resection at operation. There was one hospital death (2%). A complete response to preoperative therapy was seen in 12 patients (21%): 5 of 20 with squamous cancer (25%) and 7 of 36 with adenocarcinoma (19%). Average follow-up is 19 months. Median survival in these patients after entrance in the protocol is 24 months. Actuarial survival at 12, 18, and 24 months is 72% (confidence limits, 66% and 78%), 53% (confidence limits, 46% and 60%), and 51% (confidence limits, 44% and 58%). Significantly better survival was associated with adenocarcinoma (p = 0.041). There is no survival advantage based on complete response to preoperative therapy. This neoadjuvant regimen is effective in patients with squamous carcinoma and adenocarcinoma. These preliminary results demonstrate an improved median and actuarial survival compared with historical controls in 137 patients operated on between 1966 and 1985 at our institution.

Adenocarcinoma↗
PubMed1992

Role of hepatic nerves in response of liver to intraportal glucose delivery in dogs.

Net hepatic glucose uptake (NHGU) is much greater during oral or intraportal glucose loading than during peripheral intravenous glucose delivery even when similar glucose loads and hormone levels reaching the liver are maintained. To determine whether this difference is influenced by the hepatic nerves, nine conscious 42-h-fasted dogs in which a surgical denervation of the liver (liver norepinephrine levels postdenervation averaged 2.4% of normal) had been performed were subjected to a 40-min control period and two randomized 90-min test periods during which somatostatin (0.8 microgram.kg-1.min-1), intraportal insulin (1.2 mU.kg-1.min-1), and intraportal glucagon (0.5 ng.kg-1.min-1) were infused. The glucose load to the liver was increased twofold by infusing glucose into a peripheral vein (Pe) or the portal vein (Po). Arterial insulin and glucagon concentrations were 39 +/- 2 and 39 +/- 3 microU/ml and 55 +/- 5 and 54 +/- 7 pg/ml during Pe and Po, respectively. The hepatic glucose loads were 50.3 +/- 4.4 and 51.4 +/- 5.8 mg.kg-1.min-1 while NHGU was 2.1 +/- 0.5 and 2.2 +/- 0.7 mg.kg-1.min-1 during Pe and Po, respectively. Similar hormone levels and glucose loads reaching the liver in dogs with intact hepatic nerve supplies were previously shown to be associated with NHGU of 1.4 +/- 0.7 and 3.5 +/- 0.8 mg.kg-1.min-1 in the presence of peripheral and portal glucose delivery, respectively. In conclusion, an intact nerve supply to the liver appears to be vital for the normal response of the liver to intraportal glucose delivery.

Administration, Oral↗
PubMed1992

Malignant lymphoma of the breast: a review of 13 cases.

Thirteen cases of primary malignant lymphoma of the breast are reported from a 15-year retrospective review of records. The ages ranged from 19 to 75 years. One patient had nodular sclerosing Hodgkin's disease and 12 had non-Hodgkin's lymphoma. Eleven patients were treated with local excision, followed by radiotherapy, chemotherapy, or both. One patient had mastectomy and chemotherapy, and one had local excision only. Four patients died 6 months to 7 years after initial diagnosis. One patient was alive and with disease 5 years later. The remainder were alive and free of disease 24 months to 9 years after presentation. Prognosis depended on the clinical stage and histologic grade of the lesion. Five-year survival was 72 per cent, which was slightly better than that observed in mammary carcinoma.

Adult↗
PubMed1991

A case of opisthorchiasis diagnosed by cholangiography and bile examination.

A case of symptomatic opisthorchiasis in a 66-year-old Laotian immigrant is presented. The diagnosis was made by transhepatic cholangiography and by finding the trematode eggs in bile fluid. The characteristic cholangiographic changes of opisthorchiasis are described, including the intraluminal filling defects, the diffuse irregular dilation of the intrahepatic bile ducts, and the abrupt endings of the terminal branches. The importance of microscopic examination of the bile is stressed especially when stool examination is negative.

Aged↗
PubMed1990

Major hepatic resection: an update.

In 1981, we reported a series of 75 major hepatic resections done over a ten-year period; 58 were for hepatic trauma, nine were for benign disease, and eight were for malignant disease. Since that report, the indications for major hepatic resection have changed, with a more conservative approach to hepatic trauma and a more aggressive approach toward hepatic tumors. In this update, we report 88 hepatic resections from Vanderbilt University Hospital and Metropolitan Nashville General Hospital; 32 were for trauma, 25 were for benign disorders, and 31 were for malignant disease. Since 1977, nine adults and four children have had hepatic resection for primary malignant tumors; there were six hepatocellular lesions, three hepatoblastomas, two malignant hemangioendotheliomas, one malignant hepatoma, and one intrahepatic cholangiocarcinoma. At the time of this writing, the four children have survived for 7.3, 6, 6, and 3.8 years (mean 5.7), and all are alive without evidence of recurrence. For the nine adults, survival has averaged 1.7 years, excluding one postoperative death. Three adult patients are alive at this writing, one of whom is a five-year survivor without evidence of disease. Seventeen adults and one child had hepatic resection for metastatic lesions. In the adults, the primary tumor was in the colon in 14 cases and in the small bowel, stomach, and an unknown site in one case each. The one child had a metastatic Wilms' tumor. Survival has averaged two years, with two long-term survivors (nine years). Six patients are alive at this time. Operative mortality for elective resection has decreased from 12% (2/17) in our earlier report to 3% (1/31) in this series, which has encouraged us to assume a more aggressive approach to the resection of malignant primary and metastatic liver tumors.

Adenoma, Bile Duct↗
PubMed1990

Primary malignant melanoma of the adrenal gland. A report of two cases and review of the literature.

Primary malignant melanoma of the adrenal gland is an established entity despite early doubts. It originates in the adrenal medulla from cells derivative of the neural crest. Because of the high frequency of metastatic involvement of the adrenal by cutaneous and ocular melanomas, rigid diagnostic criteria should be followed. Only four cases of this lesion have been reported since 1946. Review of these four together with the two described in this article shows that primary adrenal melanoma is a highly malignant tumor of middle age that often manifests as a painful flank mass. Distant lymph node metastases can be seen as a presenting sign. Treatment is not effective with a mortality rate approaching 100 per cent within two years. Since the true melanocytic origin of primary adrenal melanoma has not been established and because of the similarity of its pathologic findings with the pheochromocytomas, we believe that adrenal melanoma arises from the pheochromocytes and should be called "melanotic malignant pheochromocytoma."

Adrenal Gland Neoplasms↗
PubMed1989

Xanthogranulomatous cholecystitis. A clinical and pathologic study of twelve cases.

Xanthogranulomatous cholecystitis often presents as a severe chronic cholecystitis associated with abdominal pain, fever, and leukocytosis. Gallstones are present in most cases. At operation, there are adhesions to surrounding tissues, and sometimes a mass is found, mimicking tumor of the gallbladder. The gross and microscopic appearances are characteristic with multiple intramural nodules composed of foamy histiocytes and inflammatory cells. Cholesterol contents of these nodules are high. Involvement of the Rokitansky-Aschoff sinuses with liberation of bile lipids into the adjacent tissue is implicated in the pathogenesis of this lesion.

Adult↗
PubMed1988

Phlegmasia cerulea dolens: therapeutic considerations.

Phlegmasia cerulea dolens (PCD) is a rare venous disorder that continues to be a major therapeutic challenge. We reviewed 16 cases of PCD treated during the past 15 years; 11 of the patients were male, and the average age of all the patients was 59 years. Malignant disease was the most common underlying condition (seven patients). Venous gangrene (VG) was present in seven extremities. Three treatment methods were used alone or in combination--intravenous heparin, venous thrombectomy, and thrombolytic therapy. Heparin was used initially in 13 patients; it yielded a successful result in seven (53%) patients, none of whom had VG. Venous thrombectomy was done in six patients; in three it was the primary procedure, in two it followed failure of heparin, and in one it followed failure of both heparin and thrombolytic therapy. Venous thrombectomy was successful in three (50%) patients, one of whom had early VG. Thrombolytic therapy was used on one occasion in conjunction with both heparin and venous thrombectomy, without benefit. Five patients died, all with VG, three after heparin only, one after heparin and venous thrombectomy, and one after all three treatment methods. Review of the 38 cases reported in the recent literature shows comparable results. These data suggest that nongangrenous forms of PCD respond well to systemic anticoagulation. Combination therapy using venous thrombectomy and heparin is indicated for severe ischemia, early VG, or failure of PCD to improve after six to 12 hours of heparin therapy. Phlegmasia cerulea dolens with VG is the lethal form of the entity and responds poorly to established therapy. Future therapeutic trials need to consider aggressive use of thrombolysis with or without thrombectomy.

Adult↗
PubMed1987

Gastrointestinal lymphoma and sarcoma. A case for aggressive search and destroy.

The incidence of sarcomas of the gastrointestinal tract has remained the same, but gastrointestinal lymphomas are gradually contributing a larger percentage of malignant gastrointestinal neoplasms. The authors have examined their more recent experience with these relatively rare lesions. Twenty-eight patients (13 with lymphoma, 15 with sarcoma) have been treated at the Vanderbilt University and the Metropolitan Nashville General Hospital since 1976. There were eight men in the group with lymphoma and six in the group with sarcoma. The average age for patients with lymphoma was 66 years; the average age was 57 years in the patients with sarcoma. Seven patients with lymphoma and eight patients with sarcoma had been treated for 6 months to 3 years for presumed peptic ulcer disease. Eight of these 15 patients were found to have perforated tumors at the time of surgical exploration. Three patients (all in the group with sarcoma) had metastatic liver disease or peritoneal implants at the time of diagnosis. Treatment for most patients included resection of the tumor, followed by chemotherapy or radiation in cases of tumor perforation or metastatic disease. The survival rate for patients with lymphoma has averaged 5.5 years, with a 55% 5-year survival rate. Patients with cleaved cell tumors survived longer than those with other types of lymphoma. In the group with sarcoma, the survival rate has been 3.1 years on the average, with a 21% 5-year survival rate.

Aged↗
PubMed1987

Granular cell tumors.

A lesion of unknown etiology and histogenesis, the granular cell tumor usually arises in the skin or soft tissue. It has been reported, however, in other sites and can be multifocal. The authors have seen 31 such tumors in 26 patients in their institutions since 1970. Most (21) patients were females, and 12 patients were black. The average age was 41.8 years, excluding two newborns with a congenital granular cell myoblastoma of the gingiva. The most common site of occurrence was the skin; seven tumors originated from the trunk and five from the extremities. Four lesions were found in the breast, three on the vulva, two in the axilla, two in the gum, two in the buccal cavity, two in the esophagus, and one each in the stomach, gluteus muscle, eyelid, and bronchus. Two patients had multiple synchronous lesions. These were bilateral hand lesions in one patient, and lesions of the breast and axilla in the other. A third patient had three separate lesions which arose over the course of 5 years, involving the bronchus, the gluteus muscle, and the buccal mucosa. An additional esophageal lesion was an incidental finding 3 years after excision of a granular cell tumor of the breast. All of the tumors were removed with local, simple excision, except for the 2-cm lesion in the stomach for which a wedge resection of the fundus was necessary and the bronchial lesion for which a wedge resection of the left upper lobe of the lung was performed.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1987

Airway injuries. The first priority in trauma.

During the last 12 years, 20 patients with significant airway injuries have been treated for lesions involving the trachea, larynx, and/or bronchus. Fourteen of the injuries were the result of penetrating wounds, nine gunshot wounds, and five stab wounds. Six patients presented with blunt trauma, four as a result of motor vehicle accidents, one from a clothesline injury, and one from a crush injury. Sixteen of the 20 were males; average age was 29.6 years. Eleven patients had injuries involving only the trachea, six had isolated laryngeal injuries, two had bronchial injuries, and one patient had a combined injury of the trachea and larynx. Eleven had subcutaneous emphysema, four had hemoptysis, and three stable patients experienced sudden respiratory arrest while being evaluated for the repair of their injuries. Twelve patients required immediate intubation or tracheostomy. Most airway injuries were closed primarily. In one instance segmental resection of a perforated trachea and primary anastomosis was necessary. Two patients died after proper management of the airway injury. One died of an associated brain stem injury and the other of profuse hemorrhage from a liver injury. Of the 18 surviving patients, all but two recovered totally without residual impairment. Described here is a protocol for the evaluation and immediate treatment of airway injuries that is consistent with the guidelines of the Subcommittee of Advanced Trauma Life Support of the American College of Surgeons Committee on Trauma. Aggressive initial management, high index of suspicion for injury, and meticulous repair of the injured airway are equally important steps in the successful management of these patients.

Accidents, Traffic↗
PubMed1987

Carcinoma of the colon in patients 35 years of age and younger.

Of 705 patients who were treated at the Vanderbilt University and Metropolitan Nashville General Hospitals from 1973 to 1984 for carcinoma of the colon, 45 (6.3%) were 35 years of age or younger at the time of diagnosis. There were 25 men and 20 women; the average age was 29.3 years. Twenty-six patients (57.7%) presented with pain, 19 reported a change in bowel habits, and 18 had gastrointestinal bleeding which led to diagnostic investigation. At the time of diagnosis, only two patients had lesions which could be classified as Dukes' A, eight were Dukes' B, 28 were Dukes' C, and the remaining seven had Dukes' D lesions with distant metastasis. Nineteen patients had poorly differentiated tumors; survival in this group averaged 1 year. In the 19 patients who had well or moderately well-differentiated tumors, survival averaged 4.3 years. Fifteen patients had unresectable tumors at the time of initial treatment, and survival in this group has averaged 1.5 years. Thirty patients had tumors which were considered to be resectable by the operating surgeon, and nine of these 30 patients are alive without evidence of recurrence for an average of 5.6 years. The prognosis of carcinoma of the colon in the young has been poor, with the major factors being the unfavorable histologic features of these tumors and the advanced disease at the time of presentation in these patients. Those few patients who present early in the course of their disease respond well to radical resection.

Adolescent↗
PubMed1986

Is ileoproctostomy a reasonable procedure after total abdominal colectomy?

A 17-year study has been made of 63 patients who had a variety of colonic disorders treated by total abdominal colectomy with ileorectal anastomosis in four hospitals affiliated with Vanderbilt University. Forty-three of these patients made an uneventful recovery, but 20 others sustained significant complications, nine of which proved to be fatal (hospital mortality rate, 14%). The study shows (and confirms the work of others) that ileorectal anastomosis after total abdominal colectomy is a reasonable procedure that provides satisfactory results on a long-term basis in a majority of patients when strict criteria in patient selection are followed in its application.

Adult↗
PubMed1986

Empyema thoracis: a ten-year experience.

Over a ten-year period, 50 patients with thoracic empyema have been treated at the Metropolitan Nashville General Hospital, where a systematic, stepwise approach to the management of empyema has been followed. The initial step was thoracentesis; if this failed to resolve the empyema, dependent thoracostomy tube drainage was used. Closed thoracostomy drainage was converted to open drainage when closed drainage failed to obliterate the empyema cavity. When all other measures failed, thoracotomy with pleural decortication was done. Of the 27 patients who had empyema as a consequence of pneumonia, most (14) were successfully treated with open empyema tube drainage, though five required decortication. Eight of the ten posttraumatic empyemas resolved with open drainage, but pleural decortication was necessary in the remaining two cases. Nine patients had postoperative empyemas; six were managed with open drainage, and three resolved with closed thoracostomy drainage. Of the four remaining empyemas, two resolved with closed drainage and two required open drainage. Treatment was successful in 85% of cases, with six deaths (15%). This experience with empyema shows that early, staged surgical management is successful in most cases. In our experience, the causative organism had no bearing on outcome. Resolution of the condition was possible only after adequate drainage and obliteration of the empyema space was accomplished.

Adolescent↗