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Biomedical subjects

R M Walsh

Publications and source records attributed to R M Walsh.

At least 19 recordsLinked to original sources
PubMed2002

Retained gallbladder/cystic duct remnant calculi as a cause of postcholecystectomy pain.

BACKGROUND: Pain following cholecystectomy can pose a diagnostic and therapeutic dilemma. We reviewed our experience with calculi retained in gallbladder and cystic duct remnants that present with recurrent biliary symptoms. METHODS: Over the last 6 years, seven patients were referred to us for the evaluation of recurrent biliary colic or jaundice. There were four men and three women ranging in age from 35 to 70 years. All seven had biliary pain similar to the symptoms that precede cholecystectomy; two of them also had also associated jaundice and one had pancreatitis. The time from cholecystectomy to onset of symptoms ranged from 14 months to 20 years (median, 8.5 Years). Four had undergone laparoscopic cholecystectomy and three had had an open cholecystectomy; none had an operative cholangiogram. RESULTS: Five of seven underwent diagnostic endoscopic retrograde cholangiography (ERC), which revealed obvious filling defects in the cystic duct or gallbladder remnant. The final patient was diagnosed by laparoscopic ultrasound after eight negative radiographic studies. Four patients underwent laparotomy and resection of a retained gallbladder and/or cystic duct. Two patients were treated with extracorporeal shock-wave lithotripsy (ESWL); one of them also required endoscopic biliary holmium laser lithotripsy. One patient underwent successful repeat laparoscopic cholecystectomy. There were no treatment-related complications. At a median follow-up of 11.5 months, all have achieved complete stone clearance and are asymptomatic. CONCLUSION: Retained gallbladder and cystic duct calculi can be a source of recurrent biliary pain, and a heightened suspicion may be required to make the diagnosis. This entity can be prevented by accurate identification of the gallbladder-cystic duct junction at cholecystectomy and by routine use of cholangiography. A variety of therapeutic options can be employed to obtain a successful outcome.

Adult↗
PubMed2002

Laparoscopic vs open resection of gastric stromal tumors.

BACKGROUND: Gastric stromal tumors are rare neoplasms that may be benign or malignant. Given that malignant gastric stromal tumors rarely involve lymph nodes and require excision with negative margins, they appear amendable to laparoscopic excision. There are few reports of laparoscopic resection, and no comparisons have been done between laparoscopic and open surgery. This study compares the relative efficacy of the two approaches. METHODS: Between May 1994 and December 2000, 33 patients underwent 35 operations for gastric stromal tumors. Laparoscopic resections were performed in 21 patients; open resections were done in 12 patients. The medical records of the patients were reviewed retrospectively with regard to operating time, blood loss, length of stay, and clinical course. RESULTS: Patient demographics, tumor characteristics (mean tumor size, benign vs malignant), and presenting symptoms were similar for both groups. In the laparoscopic group, 15 wedge resections; three partial gastrectomies, and three transgastric needlescopic enucleations were performed. In the open group, six wedge resections, four antrectomies, and two partial proximal gastrectomies were performed. There were no significant differences in mean operative time (169 vs 160 min), mean estimated blood loss (106 vs 129 cc), or perioperative complication rate (9.5% vs 8.3%) between the laparoscopic and open groups, respectively. The mean length of stay was significantly less (p<0.05) in the laparoscopic group (3.8 vs 6.2 days). Average follow-up was 1.5 years. One patient in each group has died due to metastatic disease. There have been no trocar site recurrences. CONCLUSIONS: Laparoscopic resection of gastric stromal tumors is safe and appropriate. Tumor size, operating time, and estimated blood loss were equivalent to the open approach, and there was a statistically shorter hospital stay in the laparoscopic group.

Adult↗
PubMed2002

Laparoscopic splenectomy.

BACKGROUND: Laparoscopic splenectomy is currently the procedure of choice for elective splenectomy. This study reviews the initial 100 laparoscopic splenectomies completed at the Cleveland Clinic Foundation. METHODS: A retrospective review of elective laparoscopic splenectomy was performed to assess clinical outcomes at the Cleveland Clinic Foundation. Patient demographics, preoperative diagnoses, operative characteristics, morbidity, and mortality were evaluated. RESULTS: Of the 169 elective splenectomies completed over a 4-year period from 1995 to 1999, 100 were attempted laparoscopically. The proportions of all splenectomies attempted laparoscopically by year were 17%, 38%, 75%, and 72%. Nearly 70% of splenectomies were performed for idiopathic thrombocytopenic purpura or malignancy. Overall, the mean blood loss was 181 ml, and the mean operative time was 170 min. Splenomegaly occurred in 31% of the patients and accounted for longer operative times. Three patients required conversion to an open procedure. Postoperative complications were seen in 13% of the patients. One patient died in the postoperative period from staphylococcal sepsis, giving a mortality rate of 1%. CONCLUSIONS: Laparoscopic splenectomy currently is the procedure of choice for elective splenectomy at our institution. As compared with traditional open splenectomy, laparoscopic splenectomy results in minimal morbidity even in the setting of splenomegaly.

Elective Surgical Procedures↗
PubMed2002

Application of the U and gamma' models in binary sweet taste mixtures.

The U and Gamma' models of sensory interactions, successfully applied in olfaction for several years, are tested here using data from published studies on sweetness. The models are subsequently tested on new data obtained in studies of binary mixtures of four sodium sulfamates. The U model allows for the estimation of a global interaction, whereas the Gamma' model allows for the distinction between that which is due to an intrinsic interaction in the mixture itself and that which may be due to the power function exponents in the mixture. The models give satisfactory predictions for observed phenomena of sweet taste suppression, synergism or pure additivity. Additionally, they appear to be more suitable than other models recently applied in taste, particularly the equiratio model. Application of the models to the sulfamate mixtures, reveals additivity for sodium cyclohexylsulfamate (cyclamate)/potassium cyclohexylsulfamate and sodium cyclohexylsulfamate/sodium exo-2-norbornylsulfamate, respectively; whereas for sodium cyclohexylsulfamate/sodium 3-bromophenylsulfamate, the models revealed a slight hypo addition which is simply due to the dissimilarity values of the power function exponents of the components.

Aspartame↗
PubMed2001

Outcome of laparoscopic splenectomy based on hematologic indication.

BACKGROUND: Laparoscopic splenectomy is the procedure of choice for elective splenectomy at the Cleveland Clinic Foundation. Although the literature clearly documents the technical feasibility and safety of laparoscopic splenectomy, little data exists concerning the results of this procedure based on the hematologic indication for splenectomy. We sought to examine the clinical experience with laparoscopic splenectomy in a single institution, with particular attention to morbidity and clinical outcomes based on hematologic disease process. METHODS: This study retrospectively reviewed a consecutive series of laparoscopic splenectomies performed for nontraumatic, splenic pathology at the Cleveland Clinic Foundation from August 1995 to January 2001. Patient demographics, operative indications, morbidity, mortality, and clinical outcome were evaluated. Hematologic diagnostic groups were compared using Fisher's exact tests and Wilcoxon rank-sum tests. RESULTS: A total of 147 laparoscopic splenectomies were performed. Seven patients (5%) required conversion to open splenectomy. Indications for splenectomy included idiopathic thrombocytopenic purpura (ITP) in 65 patients, hematologic malignancy in 43 patients, autoimmune hemolytic anemia (AIHA) in 9 patients, thrombotic thrombocytopenic purpura (TTP) in 9 patients, splenomegaly in 5 patients, splenic cyst in 4 patients, splenic abscess in 3 patients, hereditary spherocytosis in 2 patients, splenic artery aneurysm in 2 patients, Felty's syndrome in 1 patient, myelofibrosis in 1 patient, and other in 3 patients. Accessory spleens were identified in 20 patients (14%). Postoperative complications occurred in 23 (16%) patients. Patients with ITP had significantly shorter operation times (134 vs 163 min; p = 0.001), decreased estimated blood loss (126 vs 307 ml; p = 0.001), decreased length of hospital stay (2.8 vs 4.6 days; p < 0.001), and less chance of conversion (0 vs 7; p = 0.02) than patients with any other diagnosis. A mean follow-up period of 20 +/- 14 months showed an 85% rate of remission for ITP, 89% for TTP, and 89% for AIHA. Patients with malignant disease had significantly larger spleens (822 vs 313 g; p < 0.001), more estimated blood loss (380 vs 168 ml; p = 0.04), and longer operative times (170 vs 142 min; p = 0.009), as compared patients treated for benign disease. However, the length of hospital stay (4.3 vs 3.6 days; p = 0.06) and complication rates (19% vs 14%; p = 0.08) were not significantly different between the two groups. CONCLUSIONS: When performed for ITP, laparoscopic splenectomy resulted in shorter operations, minimal blood loss, earlier discharge, no conversions, and excellent remission rates, as compared with other hematologic indications. Despite larger spleens, more blood loss, and longer operations in patients with hematologic malignancies, morbidity and length of hospital stay still were similar to those associated with benign indications for laparoscopic splenectomy. In conclusion, laparoscopic splenectomy is safe and efficacious for a multitude of benign and malignant hematologic indications, and our data compares favorably to those for open series.

Adolescent↗
PubMed2001

Pancreatic complications following laparoscopic splenectomy.

BACKGROUND: Laparoscopic splenectomy (LS) has been widely accepted despite a paucity of outcome data. Therefore, we performed a review of LS to assess the pancreatic complications and outcomes associated with this procedure. METHODS: Ninety-four splenectomies were performed for a variety of hematologic disorders. The patient was placed in the lateral position, and three or four trocars were used. RESULTS: LS was completed successfully in 93 patients. One case was converted to an open splenectomy for suspected gastrotomy. Thirty of 32 patients with splenomegaly underwent successful LS. Fifteen patients (16%) had some evidence of pancreatic injury. Six patients had asymptomatic hyperamylasemia. An injury directly associated with an adverse outcome occurred in nine cases (9.5% overall); six patients had pancreatic collections, one had a pancreatic fistula, and two developed hyperamylasemia and pain altering the length of hospitalization. Four of these nine patients did not have elevated postoperative amylase levels and were readmitted with pancreatic complications. CONCLUSIONS: LS can be performed for most pathologic conditions. Pancreatic injury is the most common morbidity associated with LS. The detection of hyperamylasemia can alert the surgeon to a pancreatic injury and alter postoperative management.

Fungemia↗
PubMed2001

Treatment of intractable epistaxis using arterial embolization.

Arterial embolization has become the procedure of choice for managing intractable epistaxis in certain centres in North America and Europe, with arterial ligation reserved for those patients in which it fails. In Ireland, the role of this relatively new technique is poorly defined. The aim of this retrospective study was to investigate the outcome of all patients who underwent arterial embolization for intractable epistaxis in Dublin since it was introduced in 1998. Embolization resulted in complete and immediate resolution of epistaxis in 10 out of 12 patients (82%). Two patients required carotid ligation because of persistent epistaxis. One other patient had a further minor epistaxis 2 days following embolization, which was treated successfully with cautery. No major complications occurred in any of the patients. This study suggests that arterial embolization is an effective and safe method of managing patients with intractable epistaxis.

Adult↗
PubMed2001

Intracranial complications of acute frontal sinusitis.

Despite advances in the diagnosis and treatment of acute frontal sinusitis, there is still significant occurrence of intracranial complications. Urgent surgical evacuation of any intracranial collection is required; however, the surgical management of the associated sinusitis remains controversial. Ten patients presented to this department over a 12-month period with subdural empyema secondary to acute frontal sinusitis. Four patients had a coexisting Pott's puffy tumour and one patient had a periorbital abscess. Each patient was managed using a multidisciplinary approach. A frontal sinus trephine/drain +/- antral washout was performed at the same time as craniotomy with evacuation of the empyema. With this approach only two patients suffered long-term morbidity in our series, in the form of persistent neurological or cognitive deficit. No patient required a definitive sinus procedure. This study emphasizes the need for the early assessment and intervention of patients with an intracranial complication secondary to acute frontal sinusitis. Further assessment of the underlying sinus disease is indicated during outpatient follow up after the acute episode.

Acute Disease↗
PubMed2001

Loss of interstitial cells of cajal and inhibitory innervation in insulin-dependent diabetes.

BACKGROUND & AIMS: Gastrointestinal complications of long-standing diabetes include nausea, vomiting, abdominal pain, diarrhea, and constipation. The pathophysiology underlying these symptoms is poorly understood. Recent evidence suggests an important role for interstitial cells of Cajal in controlling gastrointestinal motility. The aim of this study was to determine changes in interstitial cells of Cajal and enteric innervation in a patient with insulin-dependent diabetes. METHODS: A full thickness jejunal biopsy was obtained from a 38-year-old insulin-dependent diabetic with evidence for diabetic gastroenteropathy. Immunohistochemistry, confocal microscopy, and 3-dimensional reconstruction techniques were used to quantify changes in the volume of interstitial cells of Cajal and enteric innervation. RESULTS: Interstitial cells of Cajal were markedly decreased throughout the entire thickness of the jejunum. A decrease in neuronal nitric oxide synthase, vasoactive intestinal peptide, PACAP, and tyrosine hydroxylase immunopositive nerve fibers was observed in circular muscle layer while substance P immunoreactivity was increased. CONCLUSIONS: The data suggest that long-standing diabetes is associated with a decrease in interstitial cells of Cajal volume and a decrease in inhibitory innervation, associated with an increase in excitatory innervation. The changes in interstitial cells of Cajal volume and enteric nerves may underlie the pathophysiology of gastrointestinal complications associated with diabetes and suggest future therapeutic targets.

Adult↗
PubMed2001

Role of differential neuroaxial blockade in the evaluation and management of pain in chronic pancreatitis.

OBJECTIVES: Chronic pancreatic pain is difficult to treat. Surgical and medical therapies directed at reducing pain have met with little long-term success. In addition, there are no reliable predictors of response including pancreatic duct diameter. A differential neuroaxial blockade allows characterization of chronic abdominal pain into visceral and nonvisceral pain origins and may be useful as a guide to the treatment. Pain from an inflamed, and scarred pancreas should be visceral in origin. The purpose of our study was to determine the frequency with which patients with chronic pancreatitis have visceral pain and whether our modified differential neuroaxial blockade technique using thoracic epidural analgesia can accurately predict which patients will respond to medical or surgical therapy. METHODS: We retrospectively reviewed the medical records of patients with a firmly established diagnosis of chronic pancreatitis (Cambridge classification, calcifications) who had undergone a differential neuroaxial block for their chronic abdominal pain evaluation. Patient demographics and medical or surgical treatment for pancreatic pain was recorded. Response to therapy was defined by a 50% reduction in pain by verbal response score. RESULTS: A total of 23 patients were identified. Alcohol was the most common etiology for chronic pancreatitis (15 of 23, 55%). Surprisingly, the majority of chronic pancreatitis patients had nonvisceral pain (18 of 23, 78%) and only 22% (5 of 23) had visceral pain by differential neuroaxial block. Four of five patients (80%) with visceral pain responded to therapy, whereas only 5 of 17 (29%) of patients with nonvisceral pain responded. CONCLUSIONS: Surprisingly, patients with chronic pancreatitis commonly have nonvisceral pain. Differential neuroaxial blockade can predict which patients will respond to therapy.

Analgesia, Epidural↗
PubMed2001

Partial labyrinthectomy approach for brainstem vascular lesions.

Conventional wisdom has typically dictated that the bony labyrinth is an inviolate structure. This notion, however, was successfully challenged following the introduction of the partial labyrinthectomy approach, which was primarily used for the surgical management of cerebellopontine and petrous apex meningiomas. In this article, we discuss an extension of the technique of partial labyrinthectomy in a series of patients that has been used for the treatment of brainstem vascular lesions. We believe that this technique provides superior exposure to the brain stem when compared with conventional retrosigmoid and retrolabyrinthine approaches while reducing the inherent morbidity seen in transotic or petrosectomy approaches.

Adult↗
PubMed2001

The ascendance of laparoscopic splenectomy.

The application of laparoscopic techniques for abdominal procedures has been achieved with varying success. The general acceptance of laparoscopic splenectomy (LS) may be hindered by its infrequent performance and difficulty in manipulating the spleen. A retrospective review of splenectomies performed for primary splenic pathology was done to assess the role and outcome of LS. One hundred fifty LSs were performed from July 1995 through September 1999. Over that time period the proportion of LS performed increased steadily from 17 to 75 per cent of all splenectomies. The primary indications for splenectomy included immune thrombocytopenic purpura in 75 (50%), lymphoma/leukemia 36 (24%), and splenomegaly 19 (13%). There were 86 females and 64 males. Immediately before operation 36 patients (4%) had a platelet count <50,000/ mL, and 24 patients (16%) a hemoglobin <10 mg per cent. The mean operative time was 161 minutes with an average blood loss of 138 cm3 (<50-800). The mean morcellated weight of the entire group was 411 g (33-3300) indicating generally large splenic size. In the 37 patients with splenomegaly the mean weight was 735 g (293-3300). There were two conversions to open splenectomy. Two patients with hematologic malignancy, splenomegaly, and cytopenias died from overwhelming post-splenectomy sepsis (1.3%). Morbidity occurred in 14 (9%) with the most common complication being pancreatitis in seven (5%). The median length of postoperative stay was 2.4 days (range 1-5). In summary LS has rapidly replaced the open approach for nearly all elective splenectomies in adults and children. When performed with the patient in the lateral position it can be accomplished with minimal morbidity, even in complex patients, including those with splenomegaly.

Adolescent↗
PubMed2001

Laparoscopic splenectomy in patients with normal-sized spleens versus splenomegaly: does size matter?

Laparoscopic resection has become the standard means for removal of normal-sized spleens in many medical centers. The application of minimally invasive techniques in the setting of splenomegaly is less well defined and was previously considered a contraindication to the laparoscopic approach. The purpose of this prospective study of consecutive patients was to compare the outcomes of patients undergoing laparoscopic splenectomy for normal-sized spleens (150 g or less) versus those with clear evidence of splenomegaly (500 g or greater). One hundred forty-two patients met the inclusion criteria. The most common diagnosis in the normal-sized spleen group was idiopathic thrombocytopenia purpura (67 of 82, 82%). Malignant hematologic diseases (lymphoma and leukemia) were the most common diagnoses in the splenomegaly group (35 of 60, 58%). Mean operative times (127 vs 172 minutes) and estimated blood loss (123 vs 173 cm3) were lower for those patients with normal-sized spleens (P < 0.05). There were no statistical differences in conversion rates, lengths of stay, or complications between the two groups. We conclude that laparoscopic splenectomy is safe and effective in the setting of splenomegaly despite modest but statistically longer operative times and increased operative blood loss when compared with laparoscopic splenectomy for normal-sized spleens.

Adolescent↗
PubMed2001

Laparoendoscopic treatment of gastric stromal tumors.

Gastric stromal tumors are the most common submucosal mass found in the stomach. These tumors are most often diagnosed at endoscopy and can be accurately characterized by endoscopic ultrasound. They typically require surgical resection, and an increasing number of patients undergo laparoscopic resection. A combined laparoscopic/endoscopic, intragastric enucleation technique is described, and results are reported in 10 patients. Eleven nonmalignant lesions were excised, with a mean size of 4.12 (2.0 to 7.0) cm. There were no complications, and the median length of stay was 3.5 days. This surgical approach appears appropriate for predominantly intraluminal, benign-appearing lesions of the proximal stomach.

Adult↗
PubMed2000

Experience from a multidisciplinary "dizzy" clinic.

OBJECTIVE: To describe the experience of a combined otolaryngology and neurology multidisciplinary clinic in the evaluation, investigation, and management of patients with dizziness. STUDY DESIGN: Prospective clinical study. SETTING: Patients were seen in a tertiary referral, multidisciplinary clinic at The Toronto Hospital, University of Toronto, Ontario, Canada. INTERVENTION: A thorough history, formal otoneurologic examination, and appropriate laboratory investigations were performed. After their assessment, the patient's diagnoses were classified as peripheral, central, psychogenic, or undiagnosed and were then subdivided into specific clinical diagnoses. RESULTS: The first 812 consecutive patients seen in the multidisciplinary clinic from January 1, 1993 to December 31, 1998 are reported. Five hundred twenty-five (64.7%) patients were found to have a peripheral vestibular cause for their dizziness, 66 (8.1%) had a central cause, 108 (13.3%) had a diagnosis unknown, and 73 (9.0%) were thought to be psychogenic. In 40 (4.9%) patients, a peripheral and central cause were found. More than one type of peripheral disorder was noted in 17.9% of patients with a peripheral vestibular cause for their dizziness, and 12.3% of patients with a central cause for their dizziness had more than one specific type of central nervous system disorder. CONCLUSIONS: Most patients that were seen in a multidisciplinary clinic had a peripheral vestibular disorder. Central causes of dizziness were relatively uncommon. Serious diseases such as tumor, multiple sclerosis, and encephalitis were rare and unlikely to present with dizziness only. It is important to realize that a patient may have more than one type of disorder accounting for the symptoms, which may represent a spectrum of disease affecting the inner ear.

Adolescent↗
PubMed2000

The role of conservative management of vestibular schwannomas.

Although microsurgery is generally regarded as the conventional treatment of choice for most vestibular schwannomas, there remains a group of patients in whom a conservative management approach may be a desirable alternative. The aim of this study was to determine the natural history and outcome following the conservative management of 72 patients with unilateral vestibular schwannomas. The reasons for conservative management included poor general health, age, patient preference, small tumour size, minimal or no symptoms, and tumour in the only/better hearing ear. The mean duration of follow-up was 39.8 months (range 12-194 months). All patients underwent serial magnetic resonance imaging (MRI) for assessment of tumour growth. Patients were deemed to have failed conservative management if there was evidence of continuous or rapid radiological tumour growth and/or increasing symptoms or signs. The mean tumour growth rate, according to the 1995 guidelines of the American Academy of Otolaryngology/Head and Neck Surgery, was 1.16 mm/year (range: 0.75 9.65 mm/year). Approximately 83% of tumours grew at < 2 mm/year. Significant tumour growth was seen in 36.4%, no or insignificant growth in 50%, and negative growth in 13.6% of tumours. The growth rate of CPA tumours (1.4 mm/year) was significantly greater than that of IAC tumours (0.2 mm/year) (P = 0.001). Failure of conservative management, in which active treatment was required, occurred in 15.3%. The outcome of these patients appeared to be as favourable to a comparable group who underwent primary treatment, without a period of conservative management. The mean growth rate of tumours in patients who failed conservative management (4.2 mm/year) was significantly greater than that in patients who did not fail (0.5 mm/year) (P < 0.01). No factors predictive of tumour growth or failure of conservative management were identified. Deterioration of mean pure tone average (0.5, 1, 2, 3 kHz) and speech discrimination scores occurred regardless of whether radiological tumour growth was demonstrated or not. This study suggests that in a select number of cases of vestibular schwannoma, a conservative management approach may be appropriate. Regular follow-up with serial MRI is mandatory. Deterioration of auditory function occurs even in the absence of tumour growth.

Case-Control Studies↗
PubMed2000

Sensorineural hearing loss in ulcerative colitis.

Sensorineural hearing loss has been described in a small number of patients with ulcerative colitis. At present, it is not known whether this is a rare and sporadic association, or whether these reports represent an under recognised extra-intestinal manifestation of ulcerative colitis. The aim of this study was to determine the prevalence of hearing loss in patients with ulcerative colitis. Twenty patients with active ulcerative colitis (mean age 45 years) were recruited prospectively along with 20 healthy age- and sex-matched controls. Otoscopy, tympanometry and pure tone audiometry were performed. The activity of the disease was scored according to a 12-month cumulative disease activity index. No patients complained of auditory symptoms. Otoscopy and tympanometry were normal in all patients and controls. Pure tone audiometry showed significant sensorineural hearing loss over all frequencies in patients with ulcerative colitis compared with controls. This preliminary study indicates that subclinical sensorineural hearing loss is associated with ulcerative colitis. Further study is warranted to determine the nature of the relationship and its pathological basis.

Adult↗