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R Matthew Walsh

Publications and source records attributed to R Matthew Walsh.

18 recordsLinked to original sources
PubMed2006

Innovations in treating the elderly who have biliary and pancreatic disease.

Many diseases of the biliary tract and pancreas preferentially effect the elderly. Recent innovations in the evaluation and management of these disorders have directly impacted the lives of many seniors. Improved outcomes of pancreatic surgery is a good example of a positive impact in quality of life, especially when these surgeries are performed in centers of excellence. Evaluation and treatment strategies are presented for complicated calculous biliary disease, pancreatic carcinoma, and pancreatic cystic neoplasms.

Aged↗
PubMed2005

Pancreas-sparing duodenectomy is effective management for familial adenomatous polyposis.

Duodenal adenocarcinoma remains the leading cause of cancer death in familial adenomatous polyposis patients following colectomy. Stratification based on Spigelman's criteria provides a means for determining therapy. Spigelman stage IV patients have been selected for pancreas-sparing duodenectomy. Twenty-one patients underwent resection between 1992 and 2004, with a mean age of 58 +/- 11 years. The mean time from colectomy to duodenectomy was 27 +/- 13 years. Invasive cancer was found in the distal duodenum in one patient. Operative time averaged 327 +/- 61 minutes with a mean blood loss of 503 +/- 266 ml. There was no mortality, and eight patients (38%) had 14 complications: six (29%) with delayed gastric emptying, four (19%) with biliary/pancreatic anastomotic leak, one with pancreatitis, and one with wound infection. There were two reoperations: one for delayed gastric emptying and one for an early biliary leak. Mean length of stay was 15 +/- 10 days. Two late complications occurred: a stomal ulcer and an intestinal obstruction at 48 and 24 months, respectively. Mean follow-up was 79 months (range, 3-152 months). Two patients developed polyps in the advanced jejunal limb and were endoscopically treated. Pancreas-sparing duodenectomy represents a definitive treatment for advanced duodenal polyposis and can obviate the need for pancreaticoduodenectomy.

Adenomatous Polyposis Coli↗
PubMed2005

Natural history of indeterminate pancreatic cysts.

BACKGROUND: The optimal treatment for incidental asymptomatic pancreatic cysts is not known. The purpose of this study was to determine whether nonmucinous cysts by cyst-aspiration analysis can be observed safely. METHODS: A prospective protocol was initiated in September of 1999 for all suspected cystic neoplasms. Asymptomatic patients with negative cyst aspirates (no extracellular mucin, and concentration of carcinoembryonic antigen in the cyst fluid <200 ng/mL) were followed-up clinically and radiographically. RESULTS: Through December 2004, 221 patients have been evaluated, and 80 (36%) initially were operated. There were 141 (64%) patients with indeterminate cysts, 98 have been followed-up for more than 12 months. Compared with resected patients, observed patients were older (62 vs 56 y, P < .006), and had smaller cysts (2.4 vs 4.0, P = .001). At a mean follow-up period of 24 months, 4 patients (4%) were resected. The indication, time to resection, and pathology were as follows: 2 patients for symptoms (abdominal pain and obstructive jaundice) at 24 and 72 months, respectively: mucinous and serous cystadenomas; 1 patient for an increase in size (6.6 to 7.8 cm) at 18 months: lymphoepithelial cyst; and 1 patient for abdominal pain and increase in size (2.0 to 3.7 cm) at 41 months: pseudocyst. The only patient resected for a mucinous neoplasm had a cyst fluid carcinoembryonic antigen level of 896 ng/mL. In the remaining observed patients, 20 (23%) showed a decrease in cyst size, and 16 (19%) showed an increase in size (mean diameter change, 21%). CONCLUSIONS: Initial follow-up evaluation indicates that asymptomatic patients without evidence of a mucinous neoplasm by cyst aspiration can be followed clinically and with interval imaging.

Carcinoembryonic Antigen↗
PubMed2004

Predictive factors for successful laparoscopic splenectomy in patients with immune thrombocytopenic purpura.

HYPOTHESIS: Younger patients with immune thrombocytopenic purpura (ITP) and high preoperative platelet counts successfully respond to laparoscopic splenectomy (LS). DESIGN: Case series. SETTING: Private, tertiary care referral center. PATIENTS: Sixty-seven consecutive patients undergoing LS for ITP between 1995 and 2001. INTERVENTIONS: Laparoscopic splenectomy. MAIN OUTCOME MEASURES: A successful response to LS was defined as a postoperative platelet count greater than 100 x 10(3)/microL without medical therapy. Failures were classified as recurrent or refractory. Patients considered refractory to surgery did not achieve a platelet count greater than 100 x 10(3)/microL without medical therapy. Patients with recurrent ITP initially achieved a platelet count greater than 100 x 10(3)/microL, but thrombocytopenia subsequently recurred. RESULTS: Both univariate and multivariate analyses were performed for 13 preoperative variables to identify factors predictive of success following LS. At a mean follow up of 22 months, 43 patients (64%) had a successful response to LS, 14 (21%) were refractory, and 10 (15%) developed recurrent ITP. By univariate analysis, patients responding to laparoscopic splenectomy were younger (P =.005) and had a higher preoperative platelet count (P =.005). In multivariate analysis, younger age (P =.005) and a higher preoperative platelet count (P =.007) again predicted a successful response to LS. CONCLUSIONS: A successful response to LS for ITP is expected in patients younger than 50 years and in those with preoperative platelet counts greater than 70 x 10(3)/microL. These factors can be incorporated into an equation that yields a splenectomy prediction score, which predicts the success of LS for ITP.

Adult↗
PubMed2004

Laparoscopic splenectomy for autoimmune hemolytic anemia in patients with chronic lymphocytic leukemia: a case series and review of the literature.

The purpose of this study was to evaluate the safety and efficacy of laparoscopic splenectomy in patients with chronic lymphocytic leukemia (CLL) complicated by autoimmune hemolytic anemia. A series of nine such patients who underwent this procedure at our institution between August 1997 and September 2001 were retrospectively reviewed. Seven of 9 patients who underwent laparoscopic splenectomy for CLL and autoimmune hemolytic anemia achieved a complete response. One patient who initially responded relapsed 12 weeks postoperatively. Therefore, six of 9 patients showed sustained responses with a mean follow-up of 2 years, consistent with other published series. Two patients had no response, one of whom died within 3 weeks of surgery from transformed Hodgkin's disease. The only other postoperative complication occurred in a patient who developed pneumonia. We conclude that laparoscopic splenectomy is a safe and effective treatment for autoimmune hemolytic anemia in patients with CLL who fail medical therapy.

Aged↗
PubMed2004

Management of failed biliary repairs for major bile duct injuries after laparoscopic cholecystectomy.

BACKGROUND: Many bile injuries are managed without referral to tertiary centers. Management of patients referred for a primary repair, or after a failed repair, was reviewed to compare outcomes. STUDY DESIGN: Retrospective review of data collected in prospective database. RESULTS: A total of 133 patients had been treated over 12 years ending in December 2002. Forty-six (35%) were treated for failed earlier repairs and 40 (30%) had their primary surgical repair at our institution. Patients with a failed repair were referred at a longer interval (165 versus 9 days, p < 0.001), were more often diagnosed intraoperatively (28 [61%] versus 13 [33%], p = 0.009), and presented with biliary obstruction (41 [89%] versus 13 [33%], p < 0.001). Of the failed repairs, 26 patients (56%) had an earlier biliary-enteric anastomosis and 20 had primary end-to-end repair. One-third of failed repairs was successfully treated with stenting and was significantly more successful after a biliary-enteric anastomosis. Surgical revision of failed repairs was required in 27 patients (59%) and was more likely in earlier primary repairs. At a mean followup of 64 months, recurrent biliary strictures occurred in 5 patients (6%). CONCLUSIONS: Management of a failed major bile duct repair requires multiple modalities, but eventually the majority of repairs require surgical revision. Good results can be expected for all surgical biliary repairs at tertiary centers.

Adult↗
PubMed2004

A novel endolaparoscopic intragastric partitioning for treatment of morbid obesity.

Morbid obesity is a burgeoning health crisis. Significant morbidity is associated with the current gastric bypass, and, therefore, alternative surgical modalities are desired. A novel minimally invasive surgical technique, endoluminal gastric partitioning, is presented. Ten mongrel dogs underwent endolaparoscopic placement of intragastric mesh. Each circular prosthesis (Surgisis or prolene mesh) was 8 cm in diameter with a 1.5 cm central aperture. The mesh was passed transorally into the gastric lumen and secured with a laparoscopic, intragastric suturing resulting in a 30 to 50 mL proximal gastric reservoir. The operation was successfully completed in all 10 animals. Nine of 10 animals were healthy at the scheduled sacrifice date. In 2 dogs, the intragastric mesh was 100% adherent to the gastric mucosa after 7 days. Four of the final 5 dogs demonstrated some degree of mucosal adherence after 1 week. Endoluminal placement of intragastric mesh appears feasible and safe. Long-term studies are necessary to demonstrate the efficacy and long-term weight loss of this, or alternate intraluminal gastric partitioning techniques.

Animals↗
PubMed2004

Application of a new collagen-based sealant for the treatment of pancreatic injury.

Pancreatic injury is the most frequent serious morbidity that can occur following laparoscopic splenectomy. The presumed mechanism of injury is direct trauma to the pancreatic tail during hilar dissection or transection with endovascular staplers. It was our aim to study the direct application of topical sealants to a pancreatic injury to prevent a pancreatic leak. A porcine model of pancreatic injury in a normal pancreas was developed. Fourteen animals underwent midline laparotomy and subtotal (8 cm) distal pancreatectomy. The pancreas was sharply divided and minimal cauterization used. A (1/4)-inch round Jackson Pratt drain was secured to the pancreatic stump in all animals. The control group (n = 7) underwent no further treatment. Two groups underwent treatment with a sealant. Group 1 (n = 3) had a hydrogel applied to the pancreatic remnant. Group 2 (n = 4) had a biodegradable sealant of PEG (polyethylene glycol)-collagen formulation applied to the pancreatic stump by aerosol. During the postoperative period, animals were fed 2.2 lb/d of a high fat (10% lard) diet to stimulate pancreatic exocrine function. Total daily drain outputs were recorded, and drain amylase content and serum amylase concentration were measured on postoperative days 3, 7, and 10. A significant pancreatic leak was defined as a drain to serum amylase content of greater than 3:1. Animals were killed on day 10 and explored for undrained fluid collections. The pancreas was removed for histologic evaluation. Control and treatment groups were compared using repeated measures ANOVA of log-transformed data. All animals survived until elective necropsy. In group 1, average total drain outputs were not significantly less than the controls (125 mL versus 269; P = .66). The mean drain/serum amylase concentration on days 3, 7, and 10 were not significantly different between group 1 and the control group. Group 2 had significantly less overall average drainage output than controls (40 mL versus 269 mL; P = .0006). Furthermore, group 2 had a significant reduction in pancreatic leaks on days 3, 7, and 10 as measured by mean drain/serum amylase concentration. No undrained fluid collections were identified at autopsy. Based on our experimental porcine model, a novel collagen-based, biodegradable hydrogel can prevent a ductal leak following pancreatic injury. These encouraging data have fostered application by aerosol treatment to the hilar bed at laparoscopic splenectomy to diminish capsular disruption from mechanical injury.

Amylases↗
PubMed2002

Hand-assisted laparoscopic splenectomy vs conventional laparoscopic splenectomy in cases of splenomegaly.

HYPOTHESIS: Laparoscopic splenectomy (LS) is the procedure of choice for elective splenectomy. Splenomegaly may preclude safe mobilization and hilar control using conventional laparoscopic techniques. Hand-assisted LS (HALS) may offer the same benefits of minimally invasive surgery for splenomegaly while allowing safe manipulation and splenic dissection. DESIGN: A retrospective review of patients with splenomegaly undergoing conventional LS or HALS was performed. SETTING: Tertiary care referral center. PATIENTS: Hand-assisted LS was performed at the start of the operation for patients with splenomegaly; splenomegaly was determined by palpation of the splenic tip extending to the midline or the iliac crest, or by a craniocaudal splenic length of greater than 22 cm. Splenomegaly was defined as a splenic weight of greater than 700 g after morcellation. MAIN OUTCOME MEASURES: Patient demographic characteristics, operative indications, splenic weight after morcellation, morbidity, mortality, and clinical outcomes were evaluated. RESULTS: Forty-five patients with splenomegaly were identified: 31 underwent standard LS and 14 underwent HALS. The HALS group had significantly larger spleens than the conventional LS group (mean weight, 1516 vs 1031 g; P =.02). Mean operative time (177 vs 186 minutes; P =.89), estimated blood loss (602 vs 376 mL; P =.17), and length of hospital stay (5.4 vs 4.2 days; P =.24) and complication rates (5 [36%] of 14 vs 5 [16%] of 31; P =.70) were similar between the HALS and the standard LS groups. No perioperative mortality occurred. CONCLUSIONS: Hand-assisted LS is a safe and efficacious procedure for these extremely difficult cases. Hand-assisted LS provides the benefits of a minimally invasive approach in cases of splenomegaly.

Adult↗
PubMed2002

Laparoscopic splenectomy for massive splenomegaly.

BACKGROUND: Laparoscopic splenectomy (LS) is the preferred operative approach for diseases involving normal-sized spleens. Our experience with laparoscopic splenectomy in the setting of massive splenomegaly is presented. METHODS: A prospective review of patients undergoing LS for massive splenomegaly was conducted. Massive splenomegaly (MS) in adults was defined as a craniocaudal length >or=17 cm or a morcellated weight >or=600 g. In children, spleens measuring fourfold larger than normal for age were considered massive. RESULTS: Forty-nine patients with MS were treated with LS. The most common primary diagnoses were lymphoma and leukemia. Mean splenic length was 20 cm (15 to 27 cm), with weights ranging from 600 to 4,750 g. Twelve patients with supermassive splenomegaly (length >22 cm) required a hand-assisted laparoscopic approach. There were no conversions to open surgery. Mean operating time was 171 minutes (90 to 369). Mean blood loss was 114 cc (<30 to 600 cc). Average length of stay was 2.3 days (1 to 16). Minor postoperative complications occurred in 3 patients. CONCLUSIONS: Laparoscopic splenectomy in the setting of splenomegaly is safe and appears to minimize perioperative morbidity. In patients with supermassive splenomegaly, a hand-assisted laparoscopic approach may be required.

Adult↗
PubMed2002

Prospective preoperative determination of mucinous pancreatic cystic neoplasms.

BACKGROUND: Optimal management of pancreatic cystic neoplasms includes identification and resection of mucinous neoplasms. This study was performed to assess the accuracy of preoperative variables in determining a mucinous lesion. METHODS: Patients referred for a cystic neoplasm were prospectively assessed by presenting symptoms, blinded radiologic review, and endoscopic ultrasound-guided cyst aspirate analysis. Patients who were symptomatic, or had aspirate findings of a mucinous neoplasm were resected. RESULTS: Eighty-seven patients were enrolled over a 22-month period ending in December 2001. There were 56 (64%) women and 31 (36%) men, with a mean age of 63 (27-86) years. Thirty-five (40%) patients were resected including 24 (69%) women and 11 (31%) men with a mean age of 58 years. Twenty-eight (80%) patients who had resection were symptomatic. Specimen histology included 18 (51%) mucinous neoplasms, 8 (23%) serous neoplasms, 4 (11%) ductal or neuroendocrine carcinomas, and 3 (9%) pseudocysts. The positive predictive value (PPV) for cyst-aspirate extracellular mucin (83%) was significant in predicting a mucinous neoplasm (P =.009). No other aspirate variables (amylase, carcinoembryonic antigen, CA15-3, viscosity), or patient characteristics were predictive of final histology. Diagnostic agreement between all 3 radiologists was 8% (P =.98). At a median follow-up of 12 months, no patients who were observed required resection. CONCLUSIONS: Patients with suspected pancreatic cystic neoplasms can be selectively treated on the basis of symptoms and cyst-aspirate mucin analysis. Symptomatic and mucin containing lesions should be resected.

Adenocarcinoma, Mucinous↗
PubMed2002

Intestinal malrotation: a rare but important cause of bowel obstruction in adults.

PURPOSE: Complications of intestinal malrotation are familiar to pediatric surgeons but are rarely encountered by those caring strictly for adults. The aim of this study was to review our experience with disorders of intestinal rotation in adult patients and to emphasize the clinical presentation, radiographic features, and results of surgical treatment. METHODS: Ten adult patients (mean age, 42 (range, 22-73) years) with complications of intestinal malrotation were identified by review of department records. Clinical presentation, operative treatment, and outcome were recorded. RESULTS: Nine patients presented with obstructive symptoms (five chronic and four acute). A diagnosis of malrotation was made preoperatively in all cases by a small-bowel contrast study or CT scan. Patients were treated by laparotomy with adhesiolysis (4 cases including one paraduodenal hernia and two midgut volvuli), Ladd's procedure (4 cases), or duodenopexy and cecopexy (1 case). One patient presented with an acute abdomen and was found to have appendicitis. There was no mortality. Two patients developed complications (wound infection and ileus). Two patients had recurrent episodes of small-bowel obstruction with a mean follow-up of 30 (range, 2-69) months and one required reoperation. CONCLUSIONS: Complications of intestinal rotation can occur in adult patients and may present with chronic or acute symptoms. Prompt recognition and surgical treatment usually lead to a successful outcome. The diagnosis of intestinal malrotation should be considered in any adult patient with signs and symptoms of small-bowel obstruction.

Adult↗
PubMed2002

Transduodenal extended sphincteroplasty and removal of ventral duct pancreatic calculi.

The surgical treatment of chronic pancreatitis and associated ductal calculi typically involves drainage of the main pancreatic duct or parenchymal resection. Treatment of isolated symptomatic pancreatic duct calculi is usually approached by endoscopic techniques. Herein is described a case report of operative transduodenal extraction of symptomatic pancreatic calculi of the ventral pancreas in a patient with a prior distal pancreatectomy. This case represents an uncommon yet valuable option in selected patients in whom endoscopic treatments have failed or are unavailable.

Calculi↗
PubMed2000

Hand-Assisted Laparoscopic Splenectomy.

The success of laparoscopic cholecystectomy has resulted in the broad application of minimally invasive techniques in many surgery specialties. The theoretical advantages of laparoscopy over conventional open operations, including less postoperative pain, faster overall recovery, and better cosmetic results have been achieved leading to its acceptance by surgeons and the public alike. Numerous abdominal procedures have been adapted to minimally invasive approaches including bowel resection, inguinal and ventral hernia repair, anti-reflux techniques, and solid organ removal such as splenectomy.

Journal Article↗
PubMedDate not supplied

Postoperative jejunal feeding and outcome of pancreaticoduodenectomy.

Complications following pancreaticoduodenectomy are common, partly because of nutritional debilitation. The aim of this study was to evaluate the impact of early postoperative tube feeding on outcome of pancreaticoduodenectomy and determine the best method for delivering enteral feeding. A retrospective review of 180 consecutive patients undergoing Whipple operations from 1994 to 2000 was performed. Two nonrandomized patient groups were retrospectively studied: those with early postoperative tube feeding vs. those with no planned feeding. Ninety-eight patients (54%) received postoperative jejunal feeding, whereas 82 patients (46%) did not. Jejunal feeding was delivered via a bridled nasojejunal tube in 55 patients (56%) and a gastrojejunal tube in 43 (44%). Vomiting (10% vs. 29%; P=0.002) and use of total parenteral nutrition (6% vs. 27%; P < 0.0001) were less in the jejunal feeding group as well as rates of readmission (12% vs. 27%; P=0.022), early (52% vs. 62%; P=0.223) and late (12% vs. 31%, P=0.005) complications, and infections (13% vs. 20%, P=0.014). Tube-related complications occurred in 6 of 98 patients, all of which were associated with gastrojejunal tubes (P=0.021). Early postoperative tube feeding after pancreaticoduodenectomy is associated with significantly less use of total parenteral nutrition and lower rates of readmission and complications. A bridled nasojejunal feeding tube appears to be a safe and reliable method of short-term enteral feeding.

Aged↗
PubMedDate not supplied

Novel bile duct repair for bleeding biliary anastomotic varices: case report and literature review.

An unusual case of variceal bleeding at the site of a biliary enteric anastomosis is presented. This entity can occur when a high-to-low pressure gradient forms in a variceal field. In this case the anastomotic site was the location of the pressure gradient from the high-pressure small bowel varices to the low-pressure biliary tract. This was successfully treated by disconnection of the anastomosis. The resulting biliary defect was patched with small intestinal submucosa, which functioned successfully as a scaffold for biliary epithelial ingrowth.

Adult↗
PubMedDate not supplied

Combined endoscopic/laparoscopic intragastric resection of gastric stromal tumors.

Myogenic neoplasms of the stomach are the most common submucosal mass. Their natural history is indeterminate, and surgical resection is advised regardless of size. These lesions have typically required open resection, but a variety of laparoscopic techniques have been described. We report results of endoscopically guided, laparoscopic intragastric resection. Fourteen lesions have been excised in 13 patients in the last 3.5 years. There were eight women and five men with a mean age of 57 years (range 34-72). All patients were asymptomatic, and no lesions had mucosal ulceration. Eight lesions were located at the gastroesophageal junction, two each at the incisura and posterior body, and one each in the fundus and anterior wall of the corpus. All lesions were predominantly intraluminal, and three were transmural. The diagnosis of a myogenic lesion was confirmed by endoscopic ultrasound in eight patients. The laparoscopic/endoscopic technique included two or three, 2 or 5 mm intragastric trocars; endoscopic suture passage and specimen removal; and laparoscopic intragastric suture repair of the gastric defect. The mean operative time was 186 minutes. The mean size of the resected specimens was 3.8 cm (range 1.5-7.0). There was no mitotic activity on histopathology, and all were considered pathologically benign. The median length of stay was 3.8 days (range 3-8). There was no mortality or operative morbidity. At a mean follow-up of 16.2 months (range 1-32) there has been no local recurrences. A combined laparoscopic/endoscopic intragastric resection is most appropriate for intraluminal, benign-appearing submucosal lesions of the proximal stomach.

Adult↗