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Biomedical subjects

W E Strodel

Publications and source records attributed to W E Strodel.

At least 73 records · Page 4Linked to original sources
PubMed1988

Malignancy and concomitant primary hyperparathyroidism.

Hypercalcemia is associated with a few primary malignant neoplasms and with a variety of tumors that have spread by metastases. Hyperparathyroidism is a diagnosis that is usually not considered in these patients. At our institution, 18 patients with malignant tumors presented over a 6-year period with hypercalcemia caused by hyperparathyroidism. There were five men and 13 women with a mean age of 48 years (range 24-87 years). Primary tumors in these patients included colon carcinoma (four cases), breast carcinoma (four cases), lymphoma (four cases), thyroid carcinoma (four cases), Paget's disease (one case), and lung carcinoma (one case). Metastases of the primary tumor occurred in seven patients, and in 11 patients the tumor was not metastatic or recurrent. Serum levels of calcium, phosphate, and chloride averaged 11.8 mg/dl, and 100 mEq/liter, respectively. C-terminal parathyroid hormone (PTH) levels ranged from 300 to 1,900 pg/ml with an average of 1,150 pg/ml (normal 50-340 pg/ml). At operation, a single parathyroid adenoma was discovered in 15 patients, and four-gland hyperplasia was noted in three patients. In all cases, serum levels of calcium returned to normal after operation. We conclude that patients with malignant tumors and concomitant hypercalcemia should be evaluated for the possibility of hyperparathyroidism. In cases of primary hyperparathyroidism, elevated C-terminal PTH level should be diagnostic. If hyperparathyroidism is determined to be the cause of hypercalcemia, neck exploration and parathyroidectomy are indicated.

Adenocarcinoma↗
PubMed1988

Diagnostic dilemmas in patients with cystic neoplasms of the pancreas.

Cystic neoplasms of the pancreas (CNP) are rare lesions that can be difficult to diagnose preoperatively. Twenty patients with cystic neoplasms of the pancreas including five microcystic adenomas, six benign mucinous cystic neoplasms, three malignant mucinous cystic neoplasms, two solid and papillary epithelial neoplasms, and four cystic neuroendocrine tumors were treated at a single institution between 1962 and 1987. The average duration of symptoms prior to diagnosis was 10 months. Five patients were asymptomatic. Forty percent of patients presented with an abdominal mass. Plain abdominal x-rays and UGI barium contrast studies were never diagnostic. Ultrasonography, computerized tomography (CT) and visceral angiography aided in the correct diagnosis in 28%, 36%, and 75% of patients studied, respectively. Overall a correct diagnosis was made preoperatively in only 35% of patients. Twelve of 13 patients were correctly diagnosed at laparotomy with intraoperative biopsy. Without biopsy the mass was misdiagnosed at laparotomy in five of six cases. CNP must be suspected in any patients who present with an upper abdominal mass with or without abdominal pain and no history of pancreatitis. CT may be diagnostic in up to one third of cases and should be obtained routinely to demonstrate the proximity of the lesion to other structures. Visceral angiography should also be obtained prior to operation. A generous incisional biopsy should be obtained of all pancreatic cysts that are not to be resected.

Adult↗
PubMed1988

Gastric bypass revision: lessons learned from 920 cases.

Roux-en-Y gastric bypass (RGB) is an accepted operation for the control of body weight in morbidly obese patients. Early technical complications and inadequate weight loss, well-known sequelae of this procedure, necessitated reoperation in 42 patients of 920 who underwent RGB in a 10-year period. Indications for reoperation included dilated gastrojejunal anastomosis (16), inadequate weight loss without demonstrable enlargement of the anastomosis (10), staple line breakdown (6), anastomotic obstruction (4), anastomotic leak (4), and enlarged proximal gastric pouch (2). Reoperation consisted of completely redoing the initial RGB in 20 patients, redoing the anastomosis alone in 17 patients, staple line revision in four patients, and intraoperative dilatation of the anastomosis in one patient. After initial RGB, 26 of the 42 patients (61.9%) experienced major complications. After revision of RGB, there were major complications in 21 patients (50%). In conclusion, major postoperative complications may contribute to RGB failure, RGB revision for early technical failure or inadequate weight loss is associated with a high incidence of major complications and, subsequently, negligible weight loss. Therefore repair of RGB for technical failure or complications is not recommended.

Adult↗
PubMed1988

Duodenal exclusion for management of lateral duodenal fistulas.

The first clinical application of pyloric occlusion with gastrojejunostomy (duodenal exclusion) for management of lateral duodenal fistulas was reported by Berg in 1907. More recently Berne et al. applied this procedure to treat patients with complex pancreaticoduodenal trauma and modified it to include antrectomy with Billroth II reconstruction and tube duodenostomy. Over time the indications for duodenal exclusion have gradually been expanded to include management of actual or anticipated duodenal fistulas arising from operative injury or as a complication of inflammatory or neoplastic diseases. Our recent success using duodenal exclusion and/or diverticularization to manage one patient with duodenal trauma and two patients with nontraumatic forms of duodenal injury resulting in lateral duodenal fistulas caused us to reevaluate the efficacy of this procedure and forms the basis for this report.

Aged↗
PubMed1987

Presentation and perioperative management of arterioportal fistulas.

Arterioportal fistulas (APFs) are usually traumatic in origin and may result in portal hypertension and its complications. Over six years, six patients (aged 20 to 59 years) presented with APFs. Two APFs developed after percutaneous liver biopsy, but only one was complicated (hemobilia). Neither patient was treated operatively. Four APFs occurred two days to three years after gunshot wounds. Three patients presented with gastrointestinal tract hemorrhage. All patients had abdominal bruits. Two patients underwent primary repair. One patient underwent APF resection and replacement of the superior mesenteric artery with autogenous vein. Another patient underwent APF and bowel resection. Three patients survived. One patient died of liver failure. The development of an abdominal bruit in a patient with penetrating abdominal trauma suggests APF and should prompt angiography. Elective repair is recommended before complications of portal hypertension develop.

Adult↗
PubMed1987

Critical appraisal of horizontal gastroplasty.

We evaluated 77 consecutive patients who had undergone horizontal gastroplasty over a 2 year period. Mean follow-up was 26 months (88 percent of patients) and ranged from 15 to 45 months. There were no operative deaths. Early complications were common. Stomal dilatation resulting in cessation of weight loss or in weight regain occurred in 19 patients (25 percent). Stomal stenosis occurred in four patients. Among patients with an intact gastroplasty, the percentage excess weight decreased from a preoperative mean of 142 +/- 46 percent to 80 +/- 38 percent at 1 year, 68 +/- 30 percent at 2 years, and 83 +/- 45 percent at 3 years. Fewer than 25 percent of the patients weighed less than 50 percent above ideal body weight at 2 or 3 years. In our experience, horizontal gastroplasty was associated with an unacceptably high mechanical failure rate. Using strict criteria, weight loss was generally inadequate at 2 years and not sustained, even in patients with intact gastroplasty.

Adolescent↗
PubMed1987

Blood flow and distribution in the canine pancreas.

Because of a tripartite arterial inflow, accurate determination of canine pancreatic blood flow (QP) in experimental studies remains problematic. Assessment of blood flow using a single electromagnetic flow probe on the anterior pancreaticoduodenal artery (APDA) was compared to the radiolabeled microsphere method. Distribution of QP was based on microsphere density. QP determined simultaneously with the flow probe technique and the microsphere method were 86 +/- 17 and 23 +/- 8 ml/min, respectively, (P less than 0.05). Following occlusion of the splenic artery (SA) and the posterior pancreaticoduodenal artery (PPDA), QP measured by the flow probe increased to 94 +/- 27 ml/min (NS) and decreased to 19 +/- 4 ml/min (NS) using microspheres. Intrapancreatic distribution of QP was not significantly altered by occlusion of the SA and PPDA. Intrapancreatic arterial collateral is adequate to maintain blood flow to the entire pancreas even when arterial inflow is restricted to the APDA. Flow probe determinations of QP are artifactually high because they include flow to the duodenum and may also be subject to methodologic error.

Animals↗
PubMed1987

Pancreatic response to crystalloid resuscitation in experimental pancreatitis.

Restoration and maintenance of intravascular volume is crucial in acute pancreatitis to prevent hypotension and ensure normal organ perfusion. This study evaluated the hemodynamic and metabolic effects of adequate versus inadequate fluid replacement on the pancreas in a canine model of acute experimental pancreatitis. Bile-trypsin pancreatitis (BTP) was induced in 14 conditioned mongrel dogs. Lactated Ringer's solution was administered intravenously at high (HIR) and low (LIR) infusion rates (6.5 and 1.75 ml/kg/hr, respectively) to 7 dogs each for 4 h. Seven sham-operated controls (CON) received lactated Ringer's at 6.5 ml/kg/hr for 3 hr. Mean arterial pressure remained unchanged in all groups. Central venous pressure decreased in the LIR group (P less than 0.05) and remained unchanged in the other groups. Cardiac index fell uniformly (P less than 0.05) in all groups. Pancreatic blood flow (Qp) decreased in the LIR group (73%) to a significantly greater extent than in the HIR (23%) and CON (8%) groups, and in the HIR group significantly more than in the CON group. The fall in pancreatic oxygen consumption (O2Cp) in both the pancreatitis groups was significant compared to the rise in the CON group. Final changes in Qp and O2Cp from baseline were significant only in the LIR group. We conclude that inadequate crystalloid replacement after BTP results in a progressive fall in Qp and O2Cp. Vigorous fluid replacement incompletely prevents these effects.

Acute Disease↗
PubMed1987

Endoscopy in colonic volvulus.

Flexible fiberoptic gastrointestinal endoscopy has greatly simplified the diagnosis and treatment of colonic volvulus. The management of 39 patients with colonic volvulus treated over 9 years was reviewed. Five per cent were treated with rectal tube decompression alone, 23% were treated with either sigmoidoscopic or colonoscopic reduction, and 26% were treated exclusively with operation. Endoscopic reduction was attempted in nearly half of the patients in preparation for operation. Recurrent volvulus occurred in 57% of patients initially treated with endoscopic reduction alone. Sigmoidoscopic examination did not confirm the diagnosis in 24% of instances in which it was used, although colonoscopy was always diagnostic. The overall mortality rate was 8%, but increased to 25% in patients with gangrene of the colon. Three patients who later proved to have gangrene of the colon had a normal initial sigmoidoscopic examination. Two of these patients died of intra-abdominal sepsis from a perforated colon. In five patients an accurate endoscopic diagnosis of gangrene prompted immediate exploration. None of these patients died. Endoscopy is a safe and effective diagnostic tool for the initial evaluation of patients with suspected colon volvulus. In addition, endoscopy may result in therapeutic decompression and may provide visual assessment of the viability of the bowel mucosa, thus assisting in the timing of appropriate operative treatment.

Aged↗
PubMed1987

Kaposi's sarcoma appearing as a rectal ulcer.

This case report describes the occurrence of a painful rectal ulcer and associated fecal incontinence in a male homosexual with acquired immune deficiency syndrome. At biopsy, the ulcer proved to be Kaposi's sarcoma. The unusual location and the atypical gross appearance of this lesion underscore the need for an aggressive diagnostic approach to such ulcerative lesions. The advanced stage of the tumor at diagnosis and the patient's poor prognosis presented a difficult therapeutic dilemma, for which only palliative measures and local control were recommended.

Acquired Immunodeficiency Syndrome↗
PubMed1987

Somatostatinomas, PPomas, neurotensinomas.

We have reviewed data pertinent to three tumor syndromes that derive from overproduction of three GEP peptide hormones. The clinical syndrome of somatostatin excess remains well defined with diabetes, diarrhea, steatorrhea being predominant features. With the availability of assays and increasing awareness, more cases are being diagnosed in the intestine and these differ somewhat in their presentation with cholecystitis, GI bleeding, or a mass as the cardinal features. An unusual association with MEN II pheochromacytoma and neurofibromatosis is emerging. PPomas remain enigmatic. Although diarrhea is a feature, these tumors are usually silent and present with hypatomegally, abdominal pain, and jaundice because of the large size and malignant nature. Neurotensinomas remain rare and truly difficult to separate from the symptom complex produced by VIP excess. Edema, hypotension, cyanosis and flushing should alert one to the possibility of a neurotensin-secreting tumor.

Adenoma, Islet Cell↗
PubMed1987

Optimizing surgical management of symptomatic solitary hepatic cysts.

Four men and six women with symptomatic solitary hepatic cysts were encountered over an 11-year period. Average age was 49 years (range, 10 months to 67 years). Most common clinical features included right upper quadrant (RUQ) pain, a palpable RUQ mass and early postprandial satiety. Liver function studies were uniformly normal. Ultrasound and computerized tomography CT were virtually diagnostic alone or in combination. Eight patients had unilocular, simple cysts and two patients had multilocular complex cysts also designated as biliary cystadenomas. Cysts recurred in four patients treated surgically by needle aspiration, incision, and internal drainage or external catheter drainage. All four patients required reoperation, which included hepatic lobectomy in three patients and extensive unroofing in one patient. No cysts have recurred in six patients treated by extensive unroofing or excision of the cyst and none has required reoperation. One patient who underwent hepatic lobectomy for cyst recurrence after an inadequate primary procedure was found to have an unsuspected carcinoma in the cyst wall. The conclusion is that extensive unroofing of unilocular solitary hepatic cysts minimizes the likelihood of cyst recurrence and obviates the need for hepatic resection. Total cyst excision is indicated for all multiloculated cysts to avoid overlooking a biliary cystadenoma or for unilocular cysts if the biopsy specimen of the cyst wall demonstrates an unsuspected neoplasm.

Adult↗
PubMed1987

Assessment of portosystemic shunt patency and function with magnetic resonance imaging.

Magnetic resonance imaging (MRI) was performed in seven patients before and after portosystemic shunting to evaluate venous changes accompanying nonselective and selective shunt construction. The size and number of the intrahepatic portal and hepatic veins, left perirenal veins, and left upper quadrant varices were evaluated at MRI before and after shunt construction. MRI correctly diagnosed patent shunts in all seven patients. A marked decrease in the size of intrahepatic veins after a total or nonselective shunt suggests adequate portal vein and variceal decompression. Dilatation of left perirenal veins in the presence of a patent mesorenal or splenorenal shunt suggests hypertension of the left renal vein and possibly inadequate decompression of esophageal varices.

Adult↗
PubMed1986

Early variceal rebleeding after successful distal splenorenal shunt.

Of 77 patients with repeated variceal hemorrhage who underwent distal splenorenal shunt, five (6.5%) developed rebleeding despite a patent splenorenal anastomosis. Three of the five patients died. Early variceal rebleeding usually indicates shunt thrombosis but may occur with a patent anastomosis. Anatomic or functional left renal vein and/or splenic vein hypertension producing incomplete variceal decompression is generally the cause. Ineffective separation of the main portal vein from the gastrosplenic venous plexus may coexist and further intensify variceal congestion. Urgent angiographic studies and direct shunt catheterization with measurement of splenic vein, left renal vein, and inferior vena cava pressures should be performed to plan appropriate therapy. A significant gradient between the splenic and renal veins is evidence of an unsatisfactory anastomosis and should be managed by balloon angioplasty or reoperation. High splenic and left renal vein pressures with a gradient of more than 10 mm Hg between the renal vein and the inferior vena cava indicate renal vein hypertension. Initial therapy should include serial injection sclerotherapy, as renal vein hypertension will usually resolve over time as additional collaterals develop. However, persistent or recurrent variceal hemorrhage may require total portal decompression to bypass the restrictive left renal vein segment.

Adult↗
PubMed1986

Perioperative use of long-acting somatostatin analog (SMS 201-995) in patients with endocrine tumors of the gastroenteropancreatic axis.

The clinical manifestations of hormone excess caused by functioning neuroendocrine tumors of the gastroenteropancreatic (GEP) axis can be life threatening and frequently prove refractory to conventional antisecretory drugs. Administration of a long-acting somatostatin analog (SMS 201-995) proved effective in three patients with complex management problems related to GEP tumors. A patient with an insulinoma was maintained euglycemic intraoperatively with a single 100 micrograms dose of SMS given before surgery. Gastric suction in two patients with gastrinomas caused hypochlorhydric alkalosis that was preventable with preoperative SMS. Iatrogenic pancreatic fistula occurring after resection of a benign insulinoma healed within 4 days of SMS administration. This drug may be a useful adjunct in the perioperative management of patients with GEP endocrine tumors. Caution is advised regarding potential hazards related to malabsorption and gastric dysmotility.

Adenoma, Islet Cell↗
PubMed1986

Nonfunctioning malignant neuroendocrine tumors of the pancreas.

The clinical features of eight women and three men with nonfunctioning islet cell carcinoma of the pancreas were reviewed. The mean patient age was 58 years (range 44 to 75 years). Weight loss and abdominal pain were the most frequent presenting symptoms. An abdominal mass was palpable in five patients. At operation regional or distant metastases were present in 82% of patients. Only 18% of patients underwent resection for potential cure. All tumors proved histologically to be neuroendocrine in origin. Immunohistochemical staining showed positive reactivity for neuron-specific enolase and chromogranin in all tumors studied but was negative for insulin, glucagon, and somatostatin. Focal positivity for pancreatic polypeptide was seen in one tumor. Nine patients with unresectable disease at operation were available for follow-up. Mean survival for the entire group was 23 +/- 7.2 months (range 4 to 72 months). Survival differences between women and men appeared to favor women but were not statistically significant. Postoperative regional or systemic chemotherapy also had no significant effect on patient survival although two of the longest survivors (36 and 72 months) had received adjunctive chemotherapy. Nonfunctioning islet cell neoplasms are locally aggressive, have a propensity for early metastases, and are rarely resectable for cure. Unlike pancreatic exocrine carcinomas, endocrine malignancies may respond favorably to adjunctive chemotherapy.

Adenoma, Islet Cell↗