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Biomedical subjects

R W Bailey

Publications and source records attributed to R W Bailey.

At least 19 recordsLinked to original sources
PubMed1992

Laparoscopic management of acute and chronic cholecystitis.

Contrary to earlier predictions, it appears that acute cholecystitis should be considered a relative rather than an absolute contraindication to laparoscopic surgery. The most important parameter in determining the feasibility of attempting laparoscopic cholecystectomy in the setting of acute inflammation appears to be the experience of the surgeon. This also appears to be true when encountering individuals with elements of long-standing chronic cholecystitis. Although laparoscopic intervention in such patients is associated with a greater likelihood of conversion to open laparotomy, the incidence of major biliary and nonbiliary complications appears to be low. In addition, these patients enjoy the same benefits of laparoscopic surgery as those undergoing elective surgery.

Acute Disease↗
PubMed1992

Laparoscopic cholangiography. Results and indications.

One hundred sixty-five operative cholangiograms were attempted in 364 patients who underwent laparoscopic cholecystectomy (45%). Laparoscopic cholangiography was successful in 150 of 165 attempts (91%). Eighty-nine per cent of studies were normal (134/150) and 11% were abnormal (16/150). All 134 patients with normal cholangiograms remained asymptomatic (false-negative rate, 0%). False-positive studies occurred in 3 of 150 (2%) total cholangiograms and 3 of 12 (25%) abnormal cholangiograms consistent with choledocholithiasis. A total of 16 of 364 patients had proven common bile duct stones (4.4%). Eight of the sixteen stones were removed by preoperative endoscopic retrograde cholangiopancreatography/sphincterotomy. Five of sixteen stones were found at cholangiography, four of which were unsuspected (4/150, 2.6%). Retained common duct stones were found in 3 of 214 patients not undergoing cholangiography (1.4%). No complications or deaths occurred that were due to cholangiography. One biliary injury occurred (1/364, 0.3%), in a patient with aberrant anatomy who did not undergo cholangiography. Laparoscopic cholangiography is a safe technique with a success rate greater than 90%. Routine cholangiography is presently recommended for prevention of biliary injury, detection of stones in the cystic and common ducts, and for training purposes, especially during the learning phase of laparoscopic cholecystectomy.

Cholangiography↗
PubMed1992

Laparoscopic cholecystectomy: a review of 12,397 patients.

We reviewed the cumulative experience with laparoscopic cholecystectomy reported in the surgical literature, including 12,397 patients selected to undergo laparoscopic cholecystectomy, 95% of which were performed on an elective basis. Although the indications for operation varied, 90% of patients had evidence of cholelithiasis and biliary colic. Conversion to open cholecystectomy was required in 534 patients (4%); of these, 52% were converted because of acute or chronic inflammation or adhesions. Laparoscopic cholangiography was attempted in 3,696 of 9,231 patients (40%) and was successful in 84%. The incidence of major bile duct injury, minor bile duct injury, bile leak, and overall morbidity was 0.3%, 0.1%, 0.4%, and 4%, respectively. The mortality rate was 0.08%. Results from individual reports indicate that 54% to 98% of patients were discharged on the 1st or 2nd postoperative day, and 77% to 98% returned to full activity within 7 to 14 days. The incidence of bile duct injury, overall morbidity, and mortality compare favorably with published reports for open cholecystectomy. The collective data would also indicate that laparoscopic cholecystectomy is a safe and efficacious procedure that offers a viable alternative to conventional cholecystectomy.

Cholangiography↗
PubMed1992

Laparoscopic general surgery: current status and future prospects.

The capability of performing major abdominal surgery while avoiding a large abdominal incision has clear benefits for patient care. Laparoscopic cholecystectomy can reduce hospital stays and the length of the recovery period, as well as decrease postoperative pain, diminish scarring, and provide significant cost savings.

Cholecystectomy↗
PubMed1991

The use of radionuclide imaging in the evaluation of suspected biliary damage during laparoscopic cholecystectomy.

Laparoscopic cholecystectomy offers a reliable and effective alternative to the standard operative cholecystectomy with reduced morbidity and patient recovery time. We report three cases in which radionuclide hepatobiliary imaging was utilized to evaluate the integrity of the extrahepatic biliary ducts following suspected biliary damage during the procedure, documenting bile leakage in two of the patients.

Adult↗
PubMed1991

Laparoscopic guided cholecystectomy.

Cholecystectomy remains the most effective form of therapy for patients with symptomatic cholelithiasis. An alternative method of gallbladder removal, laparoscopic guided cholecystectomy, was attempted in 100 patients. Five patients required conversion of the laparoscopic procedure to an open laparotomy for the following reasons: discovery of a pancreatic malignancy in one patient, extensive adhesions in one, presence of an aberrant accessory right hepatic duct in one, common hepatic duct injury in one, and avulsion of the cystic duct in one. Both ductal injuries occurred during the early phase of the clinical program. In those patients undergoing laparoscopic cholecystectomy, 93 were discharged within 24 hours of surgery and 94 returned to normal activity within 1 week. Laparoscopic guided cholecystectomy appears to offer a number of advantages in patient care as well as a significant reduction in health care expenses for gallbladder disease. Appropriate training in laparoscopic surgery is necessary in order to avoid operative complications.

Adolescent↗
PubMed1991

The Baltimore experience with laparoscopic management of acute cholecystitis.

Laparoscopic cholecystectomy has rapidly emerged as a popular alternative to traditional laparotomy and cholecystectomy. Acute cholecystitis has been considered to be a relative or absolute contraindication to laparoscopic surgery. After gaining extensive experience in laparoscopic biliary tract surgery, this procedure was attempted in 15 patients with acute cholecystitis. All patients were operated on within 72 hours of admission. In five patients, the laparoscopic procedure was converted to an open laparotomy; in one patient, a localized abscess was found, and in the other four patients, extensive inflammation and edema precluded a safe dissection of the vascular and ductal structures. Laparoscopic cholangiography was performed in 14 patients and proved valuable in demonstrating the ductal anatomy. Patients were discharged an average of 2.7 days after the laparoscopic procedure. Laparoscopic cholecystectomy may be safely performed by experienced surgeons in patients with acute cholecystitis. To ensure a low complication rate, a low threshold for converting the procedure to an open laparotomy must be maintained if the ductal and vascular anatomy cannot be safely demonstrated.

Acute Disease↗
PubMed1991

Celiomesenteric anomaly and aneurysm: clinical and etiologic features.

The development of aneurysmal disease involving the rarely encountered celiomesenteric anomaly is extremely unusual. Aneurysmal disease of the celiac or superior mesenteric arteries is itself an extremely uncommon finding, accounting for less than 10% of all visceral artery aneurysms. The existence of aneurysmal disease involving a celiomesenteric anomaly has been alluded to only briefly in two previous clinical reports. We review the case of a young woman with aneurysmal disease involving a common celiomesenteric trunk. The patient underwent excision of the aneurysm with successful vascular reconstruction. Although extremely unusual, the development of this extremely rare lesion can be predicted on the basis of specific etiologic theories. Variations in the patterns of embryologic formation of the visceral arteries account for the development of celiomesenteric anomalies, whereas atherosclerosis, medial degeneration, and infection lead to the development of most visceral aneurysms. Surgical treatment of celiac or mesenteric aneurysms is almost always indicated. Awareness of potential vascular anomalies and patterns of collateral circulation are necessary for appropriate surgical intervention.

Aneurysm↗
PubMed1991

Laparoscopic cholecystectomy. Experience with 375 consecutive patients.

Three hundred seventy-five consecutive patients underwent laparoscopic cholecystectomy from September 1989 to January 1991. Three hundred forty-one (91%) presented on an elective basis, and the remaining 34 patients (9%) were admitted for acute cholecystitis (24), gallstone pancreatitis (9), and cholangitis (1). Of the 375 patients, 20 were converted to laparotomy and cholecystectomy, for an overall success rate of 95% for patients undergoing laparoscopic cholecystectomy. Three hundred nineteen patients (90%) were discharged within 24 hours of surgery. Operative cholangiography was completed in 141 patients, showing choledocholithiasis in five (managed by postoperative endoscopic retrograde cholangiopancreatography [ERCP] in 4, common bile duct exploration [CBDE] in 1). Two retained stones (0.9%) were detected in 214 patients not undergoing cholangiography. Three patients (0.8%) were reoperated on because of perioperative complications. Overall morbidity for patients undergoing laparoscopic cholecystectomy was 3.5%. Major complications (0.6%) included a single common hepatic duct injury and a delayed cystic duct leak at 10 days. Minor complications occurred in 11 patients (2.9%). The single perioperative death (0.3%) was due to a myocardial infarction on postoperative day 3, after an otherwise uncomplicated laparoscopic procedure. Laparoscopic cholecystectomy appears to offer significant advantages to patient recovery, and these data suggest that it can be performed with an efficacy, morbidity rate, and mortality rate similar to those of open cholecystectomy.

Adolescent↗
PubMed1991

Combined laparoscopic cholecystectomy and selective vagotomy.

Laparoscopic surgery offers distinct advantages to traditional surgery, including decreased hospitalization and recovery periods, decreased postoperative discomfort, and improved cosmesis. A feasible laparoscopic approach to the treatment of peptic ulcer disease might confer similar patient benefits. A modified highly selective vagotomy (in combination with cholecystectomy for symptomatic cholelithiasis) has been successfully completed under laparoscopic guidance in a patient with intractable ulcer disease. The patient was discharged on the second postoperative day, tolerating a regular diet. The patient's dyspeptic symptoms disappeared during the immediate postoperative period and further endoscopic evaluation revealed resolution of active ulcer disease. Although experience is still limited in the United States, initial clinical results from Europe would indicate that laparoscopic vagotomy is not only feasible but effective. With further experience, laparoscopic vagotomy may provide a viable alternative to the standard treatment of peptic ulcer disease.

Cholecystectomy, Laparoscopic↗
PubMed1991

Establishment of a laparoscopic cholecystectomy training program.

A recently developed alternative to traditional laparotomy and cholecystectomy is laparoscopic-guided cholecystectomy. This procedure has the advantages of reduced hospital stay, early return to work, diminished abdominal wall scarring, and less patient discomfort. The complex nature of this procedure and the current lack of extensive clinical experience preclude the traditional "hands-on" training normally practiced in surgical residency programs. At the University of Maryland, we have developed a program to instruct both surgeons and surgical residents in the techniques of laparoscopic surgery. Technical competence is achieved under the close supervision and guidance of an experienced laparoscopic surgeon. Training of residents in this procedure, therefore, is not very different than that for other general surgical procedures. Surgeons already in clinical practice, however, gain experience under somewhat different circumstances. Initial training involves didactic instruction through laparoscopic surgical atlases and educational videotapes. Further training uses a simulation device which enables the trainee to practice techniques of laparoscopic suturing, knot-tying, and clip application. Actual operative experience is acquired primarily in experimental animal preparations. Laparoscopic-guided removal of the gallbladder is performed in young swine (20-25 kg) under conditions that mimic those in the operating room. Further clinical experience can be acquired by assisting on several laparoscopic operations, usually involving diagnostic or pelvic procedures. Actual operative experience with laparoscopic cholecystectomy, of course, comprises the final phase of the educational program. The introduction of clinical laparoscopic training into general surgery residency programs should influence the widespread adoption of this new procedure.

Cholecystectomy↗
PubMed1987

Protection of the small intestine from nonocclusive mesenteric ischemic injury due to cardiogenic shock.

In a pericardial tamponade model of cardiogenic shock in pigs, we had previously shown that acute reductions in cardiac output produce severe mesenteric ischemia due to disproportionate splanchnic vasoconstriction. In this study, we extended the period of cardiogenic shock in order to investigate the pathogenesis of ischemic injury to the small intestinal wall. Four hours of tamponade produced sustained changes in splanchnic hemodynamics, similar to those observed in the prior short-term experiments. The resultant mesenteric ischemia caused necrotic lesions of the small intestine which were characteristic of those seen in nonocclusive mesenteric ischemia in human subjects. Prior alpha-adrenergic blockade failed to prevent either sustained mesenteric vasospasm or ischemic injury. In contrast, prior blockade of the renin-angiotensin axis, whether by nephrectomy or angiotensin-converting enzyme inhibition, blocked the splanchnic vasoconstriction, and thereby protected the small intestine from ischemic injury. The primary hemodynamic and pathologic features of this model of nonocclusive mesenteric ischemia appear to be mediated by the renin-angiotensin axis.

Animals↗
PubMed1987

The fundamental hemodynamic mechanism underlying gastric "stress ulceration" in cardiogenic shock.

Acute hemorrhagic ulceration of the gastric mucosa is seen frequently in patients with hypovolemic or cardiogenic shock. Although such lesions clearly are related to regional gastric ischemia, little attention has been directed at the underlying mechanism(s) mediating the ischemia itself. To this end, anesthetized pigs were subjected to sustained cardiogenic shock (mild hemorrhage and pericardial tamponade) such that cardiac output was reduced to 38 +/- 1% of the baseline level for 4 hours, followed by release of the tamponade, reinfusion of the shed blood, and resuscitation for 2 hours. During the period of shock, there was profound regional gastric ischemia, resulting from severe and disproportionate gastric vasoconstriction. "Blinded" gross and microscopic evaluation of the stomachs removed after the experiment revealed severe mucosal ischemic necrosis, hemorrhage, and ulceration, whereas sham-operated pigs showed no lesions. The characteristics of this model therefore mimic the essential features of the gastric "stress ulceration" syndrome. Prior confirmed total alpha-adrenergic blockade with phenoxybenzamine failed to alter these features significantly. In contrast, prior ablation of the renin-angiotensin axis, whether by angiotensin-converting enzyme inhibition with teprotide or by bilateral nephrectomy, significantly and substantially ameliorated the ischemia, vasospasm, and mucosal injury. In this model of cardiogenic shock, acute gastric mucosal "stress ulceration" is caused by a disproportionately severe regional gastric ischemia resulting from selective splanchnic vasospasm that is unaffected by sympathetic blockade but abolished by prior ablation of the renin-angiotensin axis. Like nonocclusive small bowel ischemia, ischemic colitis, and the "shock liver" syndrome, gastric "stress ulceration" is yet another component of the multiple splanchnic organ failure syndrome that appears to be mediated primarily by the remarkable sensitivity of the splanchnic vascular bed to the renin-angiotensin axis.

Animals↗
PubMed1986

Pathophysiology of hepatic ischemia in cardiogenic shock.

The hepatic hemodynamic response to cardiogenic shock was investigated in a porcine model produced by pericardial tamponade to better understand the pathophysiology of postshock hepatic insufficiency. Reductions of cardiac output to 50 percent of baseline levels produced marked hepatic ischemia by causing disproportionate reductions in blood flow through the celiac and hepatic arteries and portal vein. These were due to selective vasoconstriction of the splanchnic resistance vessels that was mimicked without tamponade by the infusion of angiotensin II, ablated by angiotensin-converting enzyme blockade, unaffected by alpha-adrenergic ablation, and correlated closely with levels of plasma renin activity. The ischemic liver injury of cardiogenic shock appears to be largely due to an exquisite responsiveness of the splanchnic vascular smooth muscle to endogenously released angiotensin II.

Angiotensin II↗
PubMed1986

Pathogenesis of nonocclusive ischemic colitis.

The nonocclusive component of ischemic colitis in anesthetized pigs was mimicked using cardiogenic shock produced by pericardial tamponade. Increases in pericardial pressure produced decreases in arterial pressure (PA) and cardiac output (CO), with corresponding rises in total peripheral resistance (i.e., cardiogenic shock). This was associated with marked reductions in blood flow through the inferior mesenteric artery (IMA), due primarily to disproportionate increases in IMA vascular resistance. Levels of plasma renin activity correlated closely with these changes in mesenteric hemodynamics. Confirmed, total alpha adrenergic blockade with phenoxybenzamine failed to block this selective mesenteric vasoconstriction, while ablation of the renin-angiotensin axis with captopril completely abolished it, thereby ameliorating the colonic ischemia. Central intravenous infusions of pathophysiologic levels of angiotensin II, without tamponade, mimicked the response to shock seen with tamponade alone. In an additional group of pigs, 4 hours of sustained shock (tamponade) followed by 2 hours of normotension (release of tamponade and resuscitation) produced lesions characteristic of ischemic colitis, including full-thickness mucosal ulceration. Such lesions were ameliorated significantly in pigs in which the renin-angiotensin system had been ablated by bilateral nephrectomy. Nonocclusive ischemic colitis appears to be mediated primarily by a remarkable sensitivity of the colonic vasculature to the renin-angiotensin axis.

Animals↗
PubMed1985

Control of gastric vascular resistance in cardiogenic shock.

That local splanchnic ischemia is associated with the acute gastric "stress" erosions seen in shock is well established. The hemodynamic mechanism mediating that ischemia is unknown. Pericardial tamponade was produced in anesthetized pigs while hemodynamic parameters were monitored in the systemic circulation as a whole and in the vascular beds of the celiac and left gastric arteries, respectively. Stepwise increases in pericardial pressure produced progressive decreases in arterial pressure and cardiac output (i.e., reproducible, quantitable, and rapidly reversible levels of cardiogenic shock). This produced a profound reduction in blood flow in the celiac and gastric beds that was significantly disproportionate to the reduction in cardiac output. This was due to significant increases in celiac and gastric vascular resistance that were more than twice as great as those seen in the systemic circulation as a whole (i.e., selective splanchnic vasoconstriction). This response was abolished by ablation of the renin-angiotensin axis, whether by bilateral nephrectomy, captopril, or saralasin, and mimicked, without tamponade, by the infusion of angiotensin II. Levels of celiac artery blood flow and resistance correlated significantly with endogenous levels of plasma renin activity. On the other hand, this response was not abolished by confirmed alpha-adrenergic blockade (phenoxybenzamine) or by sympathectomy. In this model, cardiogenic shock produces regional splanchnic ischemia in the celiac and gastric vascular beds by inducing a severe and disproportionate vasospasm that is mediated primarily by the renin-angiotensin axis.

Animals↗
PubMed1985

Long-term results of tibiotalar arthrodesis.

One hundred and one tibiotalar arthrodeses were performed using a single surgical technique that has not been previously reported. The average follow-up was ten years (range, two to twenty-five years). The rate of pseudarthrosis was 5 per cent, four to five times less than in other recent large reports. Pseudarthrosis occurred only in patients with a sensory deficit. Secure fusion was radiographically documented in 95 per cent and the functional clinical result was good to excellent in 90 per cent. The ideal fusion position was found to be neutral or slight equinus angulation, and varus-valgus angulation equal to that of the contralateral side. More than 7 degrees of varus angulation of the heel was associated with symptomatic lateral metatarsalgia in all feet in which it occurred. Radiographic measurement documented an average 85 per cent (11-degree) increase in postoperative tarsal motion. Neither symptoms nor function correlated with the degree of tarsal hypermobility.

Adolescent↗