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Biomedical subjects

R J Freeark

Publications and source records attributed to R J Freeark.

At least 19 recordsLinked to original sources
PubMed1992

The role of prophylactic subtotal colectomy in metachronous carcinoma of the colon and rectum.

The risk of metachronous carcinoma of the colon and rectum at 40 year follow-up evaluation is as high as 30 percent. Because of this risk, we reviewed a series of 767 patients treated surgically for carcinoma of the colon and rectum to define a possible prophylactic role for subtotal colectomy. Patients being treated for metachronous carcinoma of the colon and rectum represented 1.6 percent of all patients undergoing surgical treatment for carcinoma of the colon and rectum during this period. There was an early group (less than 2.5 years) and a late group (greater than eight years); with respect to time interval between lesions, the early group possibly representing missed synchronous lesions. Forty-six percent of the patients had associated adenomas. Evaluation of the colon with preoperative colonoscopy may eliminate the "early" metachronous lesions that are probably missed synchronous lesions. The presence of adenomas in a younger patient with a primary carcinoma of the colon and rectum represents a high risk of future carcinoma. Subtotal colectomy should be considered in these patients and may also improve the life-long follow-up evaluation required by allowing proctosigmoidoscopy alone to evaluate effectively the remaining colon and rectum.

Aged↗
PubMed1991

Efficacy of intraperitoneal antibiotics in the treatment of severe fecal peritonitis.

A study was performed with rabbits to examine the efficacy of treatments for fecal peritonitis and, specifically, to determine whether it is beneficial to include antibiotics in the saline used to irrigate the peritoneum. A standardized inoculum of human stool suspension was placed in the peritoneal cavity of the rabbits. Fifty-six rabbits were studied to compare the effect of treatments begun 2 hours after peritoneal soiling. The administration of no treatment resulted in 100% mortality (14 of 14). Parenteral cefotetan 25 mg/kg intramuscularly (IM) twice a day (BID) with no other treatment reduced mortality to 50% (p less than 0.05). Cefotetan 25 mg/kg IM BID plus irrigation of the peritoneum with plain saline further reduced mortality to 21% (3 of 14, p less than 0.05). Cefotetan 25 mg/kg IM BID plus irrigation of the peritoneum with saline containing cefotetan 1.0 mg/mL reduced mortality to 14% (2 of 14, p = not significant). These treatments also produced a progressive decrease in the number of intraperitoneal abscesses from 24.0 +/- 2.1 (mean +/- SEM) in the animals receiving no treatment to 9.7 +/- 1.2 abscesses in the animals receiving peritoneal irrigation with saline containing cefotetan (p less than 0.001). A second experiment then was performed specifically to examine the efficacy of intraperitoneal antibiotics. A lethal fecal inoculum was determined in rabbits receiving conventional therapy, i.e., parenteral antibiotics (cefotetan) and irrigation of the peritoneum with plain saline. With two hours delay before treatment, cefotetan 25 mg/kg IM BID and irrigation with plain saline produced 80% mortality (11 of 14). Cefotetan 25 mg/kg IM BID plus cefotetan 1.0 mg/mL in the saline washout reduced mortality to 21% (3 of 14, p = 0.003) and markedly reduced the number of intraperitoneal abscesses from 13.4 +/- 0.7 in the animals receiving irrigation with plain saline to 8.1 +/- 0.8 in the animals receiving irrigation with saline containing cefotetan (p less than 0.0001). Thus, intraperitoneal irrigation with antibiotics was highly effective. Serum antibiotic levels drawn 30 minutes after irrigation were 112.7 +/- 22.4 micrograms/mL in animals that received irrigation with plain saline, and 101.7 +/- 15.2 micrograms/mL in animals that received irrigation with saline containing cefotetan. These serum levels were not significantly different. With 6 hours delay before treatment, all therapy was less effective. Cefotetan 25 mg/kg IM BID and irrigation with plain saline resulted in 100% mortality (14 of 14). With 6 hours delay, cefotetan 25 mg/kg IM BID and irrigation with saline containing cefotetan reduced mortality to 80% (11 of 14).(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗
PubMed1991

Hemodynamic effects of pressure support ventilation in cardiac surgery patients.

Hemodynamic consequences of pressure support ventilation (PSV) were compared with intermittent mandatory ventilation (IMV) in 20 patients following aortocoronary bypass. On the morning following surgery, all patients were weaned by IMV to a rate of eight breaths per minute, tidal volume of 12 ml/kg and inspired oxygen concentration of 40 per cent. With patients awake and able to breath spontaneously, PSV was begun at 20 cm of water. In patients with static lung compliance, less than 0.06 l/cm H2O, 30 cm H2O of PSV was used. Subsequently, all patients were weaned to PSV 10 cm of water, continuous positive airway pressure (CPAP) at 5 cm water and extubated. Hemodynamic data including oxygen transport were obtained at each level of PSV and at IMV prior to weaning. Analysis using ANOVA showed comparable hemodynamic and oxygen transport parameters for PSV of 30 cm H2O in comparison with IMV. PSV at levels of 20 and 10 cm H2O produced statistically significant increases in heart rate, mean arterial pressure, central venous pressure, and pulmonary capillary wedge pressure. Cardiac output was stable, and these increases were not clinically significant. In awake patients following cardiac surgery, PSV up to 30 cm H2O can be safely applied without hemodynamic embarrassment in patients with good left ventricular ejection fractions.

Blood Gas Analysis↗
PubMed1990

Postoperative chylous ascites: diagnosis and treatment. A series report and literature review.

The accumulation of chylous fluid in the abdominal cavity is an infrequent yet alarming complication in abdominal surgery. Excessive lymphatic leakage is occasionally encountered in the course of operations at the base of the mesentery or retroperitoneum. A source can usually be identified and the leak controlled at the time of laparotomy by suture or clip. In the region of presumed leakage the importance of these efforts is reinforced by the are patient in whom such leakage persists, creating problems in recognition and management postoperatively. The development of this complication in a patient undergoing total abdominal colectomy and left-sided hepatic lobectomy prompted a review of our experience and a literature review. We report four cases of postoperative chylous ascites seen over 5 years. The fluid accumulation followed operations on the abdominal aorta (two patients) and on the colon and liver (one patient) and after a mesocaval shunt procedure (one patient). Two patients responded to low-fat, medium-chain triglyceride diets; one patient required peritoneovenous shunting; and one patient died of progressive nutritional deterioration. We review the recognition and management of chylous ascites based on our experience and that reported elsewhere.

Aged↗
PubMed1990

Mortality and quality of life after total abdominal colectomy.

We have reviewed the results of 107 consecutive total abdominal colectomies performed at our institutions during the past 10 years. Indications for surgery were carcinoma of the colon (60), multiple polyps (nine), diverticular disease (31), and other conditions (seven). Seven (6.5%) were emergency operations. All patients had anastomosis of the terminal ileum into the lower rectum or distal sigmoid colon no more than 25 cm above the anus. Thirty days after surgery, two patients (1.8%) had died of complications of anastomotic leaks. Both were poor candidates for primary reanastomosis. Morbidity was low, occurring in 11 patients (10.3%). Follow-up evaluation of bowel function revealed satisfactory results in 102 patients (95%). Five patients (5%) had experienced chronic debilitating diarrhea. Unfavorable results were more common with diverticular disease than with neoplasia.

Adult↗
PubMed1989

Less is better. The diagnostic workup of the patient with obstructive jaundice.

The typical patient with suspected obstructive jaundice is often subjected to an extensive preoperative workup on the premise of providing surgeons with information that will aid them at exploration. A 15-year review of 83 patients with obstructive jaundice from the common periampullary carcinomas was carried out and indicated that obtaining such information was unnecessary, unsafe, costly, and time-consuming. It is recommended that the patient with a medical history and liver function test results suggestive of obstructive jaundice should undergo an abdominal ultrasound study. If this discloses distal bile duct obstruction, no further tests are necessary in most patients and the operation should be carried out promptly.

Adult↗
PubMed1989

The value of continuous 72-hour peritoneal lavage for peritonitis.

Studies were performed in 120 rabbits to determine whether 72-hour peritoneal lavage is beneficial or harmful in the treatment of peritonitis. Results showed that against a high concentration fecal inoculum (90 percent mortality), peritoneal lavage containing gentamicin and clindamycin reduced mortality to 10 to 20 percent (p less than 0.05). Parenteral antibiotics alone and lavage not containing antibiotics did not decrease mortality. By contrast, against a low fecal inoculum (30 percent mortality), peritoneal lavage containing gentamicin and clindamycin did not alter mortality. However, lavage not containing antibiotics increased mortality to 70 to 80 percent (p less than 0.05). These data demonstrate that continuous peritoneal lavage may be helpful in the treatment of peritonitis provided the lavage solution contains antibiotics and may be harmful if it does not contain antibiotics.

Animals↗
PubMed1989

Institutionally shared trauma rotations are viable solutions to deficiencies in trauma training.

Numerous national trauma leaders have expressed concern about the lack of uniformity of trauma training in this country. In 1984 we instituted a trauma rotation between the University of Louisville (U.L.), with a large trauma volume, and Loyola University (L.U.) in the planning stages of trauma center development. Third year L.U. residents rotated at U.L. in 3-month blocks with an increased level of responsibility monthly, culminating in major decision-making roles and operative treatment under the chief resident's direction. The L.U. residents functioned as full members of the team and not as passive observers. Fifteen L.U. residents and 12 U.L. residents rotated during this period. Yearly major trauma visits, helicopter flights, and trauma service admissions average 1,908, 700, and 1,520, respectively. U.L. chief residents averaged 136 major operative trauma cases and 115 nonoperative trauma cases each were managed during this time period (RRC records greater than 85th percentile for all U.L. residents). L.U. residents performed an average of 30 major operative cases, nine as teaching assistant, in 3 months. Each managed more than 75 nonoperative cases. Several elements are critical in such a multi-institutional rotation: 1) active communication among the program directors, 2) commitment to one sharing arrangement only, 3) financing and malpractice for off-site residents, 4) housing, and 5) the ability to assimilate off-site residents as true trauma team members. The resident-to-resident interplay is crucial and has succeeded because both residency staffs have had excellent early training.(ABSTRACT TRUNCATED AT 250 WORDS)

Academic Medical Centers↗
PubMed1988

Plasma catecholamine changes during excision of pheochromocytoma.

Sequential changes in plasma norepinephrine (NE) and epinephrine (EPI) concentration were correlated with changes in blood pressure and cardiac rate in 14 patients undergoing surgery because of pheochromocytoma. All patients had elevated preoperative plasma catecholamine levels that increased during induction of anesthesia, intubation, and skin incision, but mean values did not become significantly higher than preoperative values until tumor manipulation. Episodes of hypertension were associated with increased plasma catecholamine levels, and plasma catecholamine levels and blood pressure decreased dramatically after tumor resection. NE and EPI were usually secreted simultaneously, but release of either NE or EPI alone occurred on some occasions. There were marked variations in the concentration ratio of NE to EPI in plasma at different periods of observation, which suggests that pheochromocytomas release varying amounts of catecholamines in a random fashion. Studies of the effect of the duration of preoperative preparation on intraoperative blood pressure, pulse rate, and cardiac arrhythmias failed to demonstrate that treatment for 14 days or longer was more effective than treatment for 4 to 7 days. Neither the brief nor the prolonged period of therapy prevented development of severe hypertension during tumor manipulation.

Adolescent↗
PubMed1986

Radiologic diagnosis of an intra-abdominal abscess. Do multiple tests help?

A review was made of the charts of 94 patients who underwent ultrasonography (US), computed tomography (CT), and gallium citrate Ga 67 (Gall) scan to rule out intra-abdominal abscesses. Of all the clinical and laboratory data, only the presence of pain and tenderness differentiated patients with and without abscesses. A review of radiologic data showed that CT was superior to US, and that US was superior to Gall scan with regard to sensitivity, specificity, accuracy, and positive and negative predictive values. When multiple radiologic tests were performed, results agreed in 72% of cases; therefore, the additional tests were essentially redundant. When radiologic test results disagreed, accuracy rates were CT, 0.86; US, 0.00; and Gall scan, 0.44. These findings suggest that, except to rule out pelvic abscesses in the presence of pelvic inflammatory disease, CT is usually the only special radiologic test that should be performed to localize a suspected intra-abdominal abscess.

Abdomen↗
PubMed1977

Blunt torso trauma.

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Abdominal Injuries↗
PubMed1976

Diverticulum of the hepatic duct: a rare anomaly.

A diverticulum of the hepatic duct was found in a 25-year-old woman. Cholangiography revealed that the diverticulum was cystic in nature and contained several stones. Since the intrahepatic ducts are never seen at surgery, the authors stress the importance of preoperative and operative cholangiography in locating such anomalies.

Adult↗