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T L Dent

Publications and source records attributed to T L Dent.

At least 19 recordsLinked to original sources
PubMed1992

Training, credentialing, and evaluation in laparoscopic surgery.

Laparoscopic cholecystectomy has become the procedure of choice for the treatment of gallbladder disease. Many general surgeons have incorporated laparoscopic cholecystectomy into their clinical practices, usually after completing a postgraduate didactic and laboratory animal training course. This additional formal training is both appropriate and necessary because laparoscopic surgery involves techniques different from those of traditional celiotomy, and most surgeons who completed their residencies prior to 1992 have had no laparoscopic training. Because additional formal training for practicing surgeons is necessary at this time, it is appropriate for hospitals to mandate separate granting of operative privileges for laparoscopic surgical procedures. In the near future, when graduates of general surgery residency programs have had training in laparoscopic surgery, separate privileges will no longer be necessary, and laparoscopic procedures should be included in the standard privilege category of biliary tract surgery. Once privileges in laparoscopic surgery are granted, laparoscopic operations, like all surgical procedures, should be monitored by peer review to ensure that they continue to be performed safely and appropriately. Only those laparoscopic procedures that are similar to open operations and have been shown by pilot studies to be safe (e.g., cholecystectomy) should be included currently in a surgeon's laparoscopic privileges. Laparoscopic procedures that are very different from proven open procedures and are investigational (e.g., inguinal herniorrhaphy) should be permitted by the hospital only as part of an experimental protocol monitored by an institutional review board. Only after their safety and efficacy have been established should they become part of standard privilege categories.

Credentialing↗
PubMed1991

Training, credentialling, and granting of clinical privileges for laparoscopic general surgery.

Despite the lack of scientific data comparing it with traditional open operations, laparoscopic surgery has gained rapid acceptance and implementation by general surgeons. Individual hospitals, which have the responsibility for developing their own privileging criteria, are searching for guidance as to the amount and type of additional training required to grant clinical privileges in laparoscopic general surgery. Laparoscopic surgery involves techniques different from those learned during general surgery residency training. Therefore, until such techniques are regularly included in general surgery residency programs, additional training for and granting of separate privileges in laparoscopic surgery are appropriate. Adequate training for surgeons already experienced in abdominal and biliary tract surgery can be acquired through a preceptorship in diagnostic laparoscopy, attending a course in laparoscopic surgery that includes both didactic instruction and live animal experience, assisting with the procedures in humans, and being proctored and certified as competent by an experienced general surgeon.

Animals↗
PubMed1989

Endoscopic screening and surveillance for gastrointestinal malignancy.

In the US, the cumulative lifetime risk of developing carcinoma of the upper gastrointestinal tract is less than 1 per cent, premalignant conditions are uncommon, and esophageal and gastric malignancies are rarely curable even when identified early. Endoscopic screening of the upper gastrointestinal tract in asymptomatic persons thus cannot be justified. Surveillance of persons with certain uncommon conditions associated with a higher risk of upper gastrointestinal cancer may be of benefit. These conditions include achalasia, Barrett's esophagus, chronic atrophic gastritis with intestinal metaplasia, familial polyposis coli, gastric polyps, lye stricture, Plummer-Vinson syndrome, and tylosis. In the lower gastrointestinal tract, however, the lifetime risk of developing carcinoma is 5 per cent, premalignant conditions and lesions are common, and carcinoma is curable when detected at an early stage. Sigmoidoscopic screening of asymptomatic adults has been advocated by the American Cancer Society but has not become widely practiced because of its cost, required physician effort, low overall yield, and poor patient compliance. Surveillance by flexible sigmoidoscopy is recommended for persons at slightly increased risk of colorectal carcinoma who have prior breast or gynecologic malignancy or a family history of colorectal malignancy. Colonoscopic surveillance is recommended for patients with high risk of colorectal cancer who have had prior colorectal carcinoma or adenoma or who have inflammatory bowel disease or a ureterosigmoidostomy.

Endoscopy↗
PubMed1987

Management of common gynecologic problems encountered during abdominal exploration.

Although general surgeons receive little training in the management of gynecologic conditions, they should be able to make intraoperative decisions about unexpected gynecologic abnormalities encountered during abdominal exploration. This report examines the six most common gynecologic problems found during abdominal exploration (salpingitis, tubo-ovarian abscess, ectopic gestation, endometriosis, uterine mass, and ovarian mass) and reviews their proper management with particular emphasis on conserving reproductive function.

Abdomen↗
PubMed1985

Bleeding lipomas of the upper gastrointestinal tract. A diagnostic challenge.

Submucosal lipoma of the upper gastrointestinal tract is a rare benign tumor. However, it may present as both a diagnostic problem and as a life threatening lesion due to exsanguinating hemorrhage. The authors report four patients with significant upper gastrointestinal bleeding due to ulcerating lipomas. In two patients the lesions were gastric and in two patients the lesions were duodenal in origin. In no instance could the diagnosis of lipoma be accurately established short of operative intervention because of unusual morphologic features. Surgical extirpation was necessary to stop the bleeding and establish the histologic diagnosis of the tumor.

Adult↗
PubMed1985

Routine endoscopy of the upper gastrointestinal tract in the evaluation of obstructive jaundice.

Our experience with flexible end-viewing EGD in the patient with jaundice demonstrated an over-all low specificity (19 per cent) for clinically significant lesions in this patient population. The discovery of synchronous lesions of the upper gastrointestinal tract in 12 patients did not change our diagnostic or therapeutic planning. Therefore, we believe that there is little justification for the increased costs and patient discomfort involved in routine EGD which should be abandoned in instances of obstructive jaundice and should be used only when more specific indications for its use are present.

Adult↗
PubMed1984

Detection of occult colovesical fistula by the Bourne test.

The value of different diagnostic tests in the detection of colovesical fistulas was studied in 28 surgically proven cases seen during the last 10 years at the University of Michigan, Ann Arbor. Etiologies were diverticulitis (19), Crohn disease (three), postradiation therapy (four), previous trauma (one), and bladder carcinoma (one). The fistulas were demonstrated by barium enema in 10 of 20 patients and by cystography in eight of 26. Cystoscopy was diagnostic in 11 of 25 patients and sigmoidoscopy in four of 24. Methylene blue test was positive in five of six patients, and in one patient given a charcoal enema the material appeared in the urine. The Bourne test, consisting of radiography of the centrifuged urine samples obtained immediately after a nondiagnostic barium enema, was positive in nine of 10 patients. In seven of these 10 patients, the Bourne test was the only positive evidence of an otherwise occult colovesical fistula later proven at surgery.

Adult↗
PubMed1984

Non-obstructive colonic dilation: radiologic findings in 50 patients following colonoscopic treatment.

Fifty patients with acute onset of colonic dilatation without mechanical obstruction were evaluated before and after colonoscopic decompression. Colonic dilatation, as demonstrated radiographically, was segmental or consistent with mechanical obstruction in 33 (66%). Signs of impending cecal perforation were seen in five (10%) and these patients had colonoscopic decompression, tube cecostomy, or both. Following colonic decompression, cecal diameter may remain unchanged for two to four days, despite decreased abdominal girth and even shortening of the colon radiographically. Improvement in pain, distention, tenderness, fever and leukocytosis may precede radiographic improvement. The radiologist must recognize this entity, look for signs of impending perforation and signs of bowel shortening, with or without decompression after treatment. Barium studies of the colon should be avoided since they can hamper the endoscopic diagnosis and treatment of colonic dilatation.

Adult↗
PubMed1984

Intersphincteric proctectomy.

Conventional proctectomy for inflammatory bowel disease is followed by delayed perineal wound healing in 20% to 63% of patients and sexual dysfunction in up to 17%. Although described several times since 1967, intersphincteric proctectomy is a technique used by very few surgeons in the United States. Accurate and safe rectal mobilization is easily accomplished by dissection within the intersphincteric plane, resulting in minimal damage to the pelvic floor and pelvic nerves and a much smaller perineal wound. The records of 58 patients who underwent rectal excision were examined. Proctectomy was performed in a conventional fashion for 30 patients and an intersphincteric proctectomy was performed for 28 patients. Of the 30 conventional procedures, 20 were for ulcerative colitis and 10 were for Crohn's disease. There was complete healing of the perineal wound in 70% of the patients at 6 months and in 73% at 1 year. There were four residual deep sinus tracts. Of the 15 men, three developed impotence, one permanently. Of the 28 patients who underwent intersphincteric proctectomy, 17 had ulcerative colitis, eight had Crohn's disease, two had incapacitating proctitis, and one had cancer of the midrectum. There was complete healing of the perineal wound in 84% of the patients at 6 months and in 84% at 1 year. There were no residual deep sinus tracts. Of the 15 men, one developed impotence that resolved after 1 year. Only one patient complained of persistent anal discomfort. The morbidity rate from intersphincteric proctectomy is low and we recommend more widespread use of this technique.

Aged↗
PubMed1984

Intraoperative fiberoptic endoscopy.

Conventional endoscopy is an indispensable tool in the diagnosis and management of many patients with gastrointestinal disease. Intraoperative use of the fiberoptic endoscope permits direct visualization of the mucosal surface, eliminating the need for enterotomy in many cases. Over a 4.5-year period, 32 patients underwent gastrointestinal endoscopy during laparotomy for a wide variety of surgical problems. In 15 cases, obscure or unknown sites of upper and lower gastrointestinal bleeding were localized. Replacement of percutaneously placed biliary drainage tubes was facilitated in four cases. In three patients artifactual lesions suggested by gastrointestinal (GI) contrast studies were excluded with intraoperative endoscopy at the time of exploratory laparotomy, and in four cases, retained foreign bodies were recovered easily without the need for enterotomy. In six additional patients intraoperative endoscopy was used to localize nonpalpable colon polyps or to determine the extent of mucosal ulceration. The average time for an intraoperative fiberoptic endoscopic examination was 20 minutes. No complications resulted from this technique. In summary, intraoperative fiberoptic endoscopy is of definite value in assessing selected patients with difficult GI surgical problems encountered during laparotomy. This technique enhances the surgeon's ability to identify and treat inaccessible and occult GI lesions.

Adult↗
PubMed1983

Therapeutic and diagnostic colonoscopy in nonobstructive colonic dilatation.

Cecal perforation has been well established as a consequence of mechanical obstruction of the distal colon and has been estimated to occur in 1.5% to 7% of patients with colon obstruction. Perforation of the cecum also occurs in cases of nonobstructive colonic dilatation (NCD). Although the incidence is unknown, the mortality rate is nearly 50%. Over an eight-year period, 44 patients (mean age 59 years) underwent 52 colonoscopic examinations for presumed NCD. Twelve patients (27%) developed NCD while convalescing from a recent operation and 29 patients (66%) had major systemic disorders that preceded the development of NCD. Medical treatment for an average of 2.6 days was uniformly unsuccessful. Mean cecal diameter prior to colonoscopy was 12.8 cm (range 9.5 to 17 cm). Based on radiographic or clinical criteria, 38 patients (86%) were successfully decompressed on the initial colonoscopic examination; mean cecal diameter decreased to 8.7 cm (p less than 0.01). Perforation of the cecum during colonsocopy occurred in one patient (2%) who survived. Fourteen patients died; six deaths were attributed solely to the patient's who underwent operation. In summary, colonoscopy is a safe and effective therapeutic and diagnostic tool in cases of massive cecal dilatation. It should be considered before cecostomy in patients without radiographic evidence of pneumoperitoneum or clinical signs of peritoneal irritation.

Adult↗
PubMed1983

Treatment alternatives in renal failure and renal transplantation patients with nonobstructive colonic dilatation.

The incidence of nonobstructive colonic dilatation (NCD) is unknown, but the attendant mortality associated with perforation is nearly 50%. Patients with chronic renal failure and transplant recipients may manifest many of the conditions that have been implicated in the development of NCD. Mechanical obstruction and ischemic bowel disease must be eliminated as causes for colon dilatation. Over a four-year period eight patients (mean age 50 years) were treated for presumed NCD. Six patients with a mean cecal diameter of 12.8 cm were treated initially with colonoscopy. Five patients (83%) had successful endoscopic decompression; of the three remaining patients, one underwent urgent ileocolectomy for cecal ischemia after unsuccessful endoscopic decompression, a second (cecal diameter 13 cm) had a tube cecostomy performed as an initial procedure, and the third (cecal diameter 9 cm) was managed successfully with enemas and nasogastric suction. Two deaths occurred in the series (25%), but both were unrelated to colon distension. No complications of colonoscopy were observed. The sequelae of massive NCD (cecal ischemia, perforation, and protracted sepsis) are poorly tolerated in the immunocompromised patient. Conservative management may be employed in patients with a cecal diameter of 9 cm, but urgent diagnostic and therapeutic colonoscopy is recommended for patients with a cecal diameter of 12 cm or greater. Operative tube cecostomy may be necessary if colonoscopic decompression is unsuccessful or cannot be performed.

Adult↗
PubMed1983

Limb-threatening potential of arteriosclerotic popliteal artery aneurysms.

Eighty-eight popliteal artery aneurysms were diagnosed in 59 men and two women (mean age 67 +/- 10 years). Bilateral aneurysms affected 27 patients (44%). Aneurysm diameter ranged from 1.3 to 12 cm (mean 4 +/- 2.6 cm). Most aneurysms were symptomatic (55%). Dominant symptoms included rest pain (19%), claudication (14%), local pain (13%), and gangrene (9%). The remainder of the aneurysms were asymptomatic (45%). Aneurysm thrombosis occurred in 24% of extremities. Associated aneurysms involved the abdominal aorta (62%), iliac artery (36%), and femoral artery (38%). Aneurysms that caused local pain were larger (6.2 +/- 1.9 cm) than asymptomatic aneurysms (2.9 +/- 2.1 cm, P less than 0.01). Aneurysms smaller than 2 cm were more likely to be asymptomatic than larger aneurysms (P less than 0.05). Operative intervention was undertaken for 56 aneurysms, with aneurysmal exclusion or excision with arterial reconstruction performed most often. Four primary and five secondary major amputations were associated with thrombosed aneurysms, compared to no amputations with asymptomatic aneurysms (P less than 0.01). Thirty-two aneurysms were not treated surgically. Limb loss resulted from ischemic complications which developed in 18% of aneurysms treated without operation. The duration of follow-up for patients who had operation and those who did not averaged 62 months and 25 months, respectively. Operative treatment for all bland popliteal artery aneurysms appears justified if complications leading to major amputation are to be avoided.

Adult↗
PubMed1983

The endorectal pull-through for the management of ulcerative colitis in children and adults.

Between June 1977 and November 1981, 26 children and adults with ulcerative colitis have undergone a total colectomy, an endorectal dissection of the rectal mucosa, and an ileoanostomy. A combined abdominoperineal approach was used to perform the operation, and the mucosal-submucosal rectal tube was dissected out intact from the abdominal approach. Every patient survived the operation and showed marked clinical improvement presumably due to resection of the diseased colon. Three patients developed intestinal obstruction that was successfully treated with an enterolysis. A rectal cuff abscess and a retroperitoneal abscess were the only other complications. The postoperative stooling pattern of each patient was obtained through detailed interviews. All the patients were continent during the day and at night one month after surgery. Twenty-two patients had a median stool frequency of seven per 24 hours one month after surgery. At one year, the average number of stools was seven per day. Six patients experienced a stool frequency of seven per 24 hours two years after surgery. The results with this series of patients had encouraged the authors to continue to recommend this approach to children and adults with ulcerative colitis, since it offers an alternative lifestyle that is more attractive to certain patients than the presence of an abdominal stoma.

Adolescent↗