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Biomedical subjects

A C Moncure

Publications and source records attributed to A C Moncure.

At least 55 records · Page 3Linked to original sources
PubMed1989

Gastrocutaneous fistulas associated with pancreatic abscesses. An aggressive entity.

Previous reports of gastrocutaneous fistulas emphasize their benign nature and the probability of spontaneous healing without the need for surgical closure. In distinct contrast we report our experiences with six patients whose gastrocutaneous fistulas were caused by fulminant pancreatitis and pancreatic abscesses. High-output acid fistulas appeared days to weeks after drainage of left upper quadrant-infected collections. None occurred at the time of initial abscess drainage. Most originated high on the greater curvature of the stomach and traversed the abscess cavity. Three of six patients had previous splenectomies, but these operations were remote in time from the appearance of the fistula. Nonoperative management was successful in only two of six patients. Massive hemorrhage from the fistula tract contributed to the deaths of three patients. The pathogenesis of these fistulas appears to be consequent to gastric injury resulting from adjacent pancreatic inflammation. We conclude that (1) gastrocutaneous fistulas associated with pancreatitis are unlikely to heal even with drainage of the abscesses and are often complicated by hemorrhage, (2) surgical closure of the fistula will often be necessary and should not be unreasonably delayed, and (3) when performed in a semi-elective setting, resection of the damaged gastric segment, perhaps with an omental or serosal patch to buttress the gastric suture line, has a good chance of success.

Abscess↗
PubMed1989

Occult gastrointestinal bleeding: newer techniques and diagnosis and therapy.

Complex problems occur concerning the diagnosis and treatment of GI bleeding. How often can the exact cause and site of the bleeding be determined? What are the advantages and complications of various forms of treatment? There are no universal answers, applicable to all situations. Nevertheless, certain assumptions seem to be justified. Diagnosis of the cause of severe bleeding, often suggested by the patient's history, is confirmed most effectively by selective angiography, which should give an answer in over 95% of cases. The causes of slow, persistent bleeding, manifested either by gross blood or by positive tests for blood in the stools, are diagnosed in about the same percentage of cases by endoscopy. It is when the bleeding is intermittent and of minimum or moderate severity that determination of the site of origin is the most difficult; angiography cannot help in the majority of cases, and endoscopy can miss tiny lesions that are not bleeding at the time of examination. However, laparotomy, especially when it is combined with intraoperative enteroscopy or angiography, should reduce the number of unsolved diagnoses to under 5% of the total. Surgery is the primary method of therapy in many cases. Primary control of bleeding also can be obtained in approximately 80% of cases of severe bleeding by endoscopy, by the use of coagulation or laser, or by selective arterial infusion of pitressin. Recurrences must be treated by surgery, except in some instances where selective embolization by the angiographer may result in a cure. The surgeon must attempt to cure the hemorrhage and to prevent recurrence at a later date by such measures as gastric resection and vagotomy for bleeding duodenal ulcers to prevent stomal ulcers, or by subtotal rather than segmental colectomy for widespread colonic diverticulosis. There will be an irreducible percentage of lesions that continue to develop in other sections of the GI tract after successful primary treatment of the original cause of bleeding; AVMs, angiodysplasia, and vasculitis are examples. Fortunately, such diseases are relatively rare. It is not unreasonable today to expect that the measures discussed herein will cure bleeding in 95% of cases; if death occurs it rarely is due to hemorrhage, but to some type of organ failure.

Gastrointestinal Hemorrhage↗
PubMed1989

Simultaneous carotid and coronary disease: safety of the combined approach.

Invoking unacceptable operative risks, many institutions have adopted a conservative policy toward carotid stenosis in patients who require cardiopulmonary bypass (CPB). We have continued to apply simultaneous carotid endarterectomy/coronary artery bypass grafting (CEA/CABG) in selected patients, and in order to place operative risk in perspective, our experience with CEA/CABG was reviewed and contrasted with both CEA and CABG performed as isolated procedures. Seventy-one CEA/CABG were performed from 1978 to 1987, with the bulk of the experience (51/71) accumulated over the past 5 years. CEA/CABG was applied when the carotid lesion was severe (greater than or equal to 75% diameter stenosis). Clinical characteristics of patients with CEA/CABG (e.g., presence of unstable angina, left main coronary artery disease, and impairment of ventricular function) suggested these patients were at higher risk for complications when compared to patients with CABG alone. Yet, other factors influencing stroke risk during cardiopulmonary bypass (patient age, duration of CPB time) were similar between patients with CEA/CABG and patients with only CABG. Most complications in patients with CEA/CABG occurred in the early years of the study. Considering the recent (1983-87) patient cohorts of CEA/CABG and isolated CABG, respectively, there was no significant difference in either operative mortality (2.0% as compared to 2.2%) or perioperative stroke (2.0% as compared to 0.6%). Whereas precise patient selection criteria remain undefined, these findings verify the safety of the combined CEA/CABG approach for most patients who require treatment of both lesions.

Aged↗
PubMed1988

Transthoracic esophagectomy: a safe approach to carcinoma of the esophagus.

Transthoracic esophagogastrectomy is a safe operation. Mechanical staplers and a cervical anastomosis have been emphasized to avoid catastrophic consequences of anastomotic leaks in the chest. Transhiatal esophagectomy has been proposed to bring the anastomosis into the neck. It is meant to be a palliative procedure and consequently denies the patient the best chance for surgical cure. The emphasis should be on anastomotic technique and sound principles of surgical oncology. Since 1980, we have performed 104 esophagectomies for carcinoma of the esophagus. We used a left thoracoabdominal incision for distal tumors (64) and the Ivor Lewis technique (40) for more proximal tumors. A two-layer inverting interrupted silk suture technique was used for all anastomoses. More than 90% of the procedures were performed by resident staff. The operative mortality was 2.9% (3 patients). There were no anastomotic leaks. Five patients required between one dilation and three dilations postoperatively. A positive smoking history was present in 83 patients and substantial alcohol use, in 33. Median estimated blood loss was 500 ml, and 60% of patients required no transfusions. Major complications included pneumonia (12 patients) and reexploration for bleeding (2). Minor complications included atelectasis (71 patients), atrial fibrillation (9), ventricular arrhythmias (9), urinary tract infection (3), and wound infection (2). Squamous cancer was present in 31 patients and adenocarcinoma, in 73. Positive lymph node metastases were present in 75%. Anastomotic recurrence was documented in 6 patients. Standard techniques of esophagogastrectomy and a two-layer anastomosis will give excellent results with low mortality and acceptable morbidity.

Actuarial Analysis↗
PubMed1988

Spontaneous aortic dissection in the presence of coexistent or previously repaired atherosclerotic aortic aneurysm.

Acute aortic dissection occurred in 18 patients who had previously diagnosed atherosclerotic aneurysms of the thoracic and/or abdominal aorta. These patients were reviewed to assess the clinical course when these two forms of aortic pathology coexist. Patients were grouped according to status of their atherosclerotic aneurysm (previously repaired vs. untreated) and the segments of the aorta effected by the acute spontaneous dissection. Group 1 patients (n = 5) had previously undergone-abdominal aortic aneurysmectomy (AAA) repair, and the abdominal aortic suture line effectively terminated the dissection process. In Group 2 patients (n = 5), the acute dissection and the atherosclerotic aneurysm involved different segments of the aorta. Group 3 patients (n = 8) experienced spontaneous aortic dissection involving atherosclerotic aneurysms (five infrarenal, three thoracoabdominal), with threatened or actual rupture occurring in six patients, resulting in three deaths. In Group 3 patients, rupture occurred both at the atherosclerotic aneurysm (four patients) and at the site of the aortic intimal tear of the dissection (two patients) after AAA repair. The use of Magnetic Resonance Imaging (MRI) has proven to be highly accurate in delineating the nature and extent of pathology in recently encountered patients with complicated aortic disease. Coexistence of atherosclerotic aneurysm and acute dissection appears to increase the risk of aortic rupture, in both proximal and distal aortic segments.

Acute Disease↗
PubMed1988

Vascular complications associated with spontaneous aortic dissection.

Three hundred twenty-five cases of spontaneous aortic dissection seen at two institutions between 1965 and 1986 were reviewed to assess the incidence, morbid sequelae, and specific management of aortic branch compromise. Noncardiac vascular complications occurred in 33% of the study group, and in these patients the overall mortality rate (51%) was significantly (p less than 0.001) higher than in patients without (29%) such complications. Although aortic rupture was the strongest correlate of mortality (90%), death specifically related to vascular occlusion was common when such occlusion occurred in the carotid, mesenteric, and renal circulation. There was a strong correlation between stroke and carotid occlusion (22/26 cases), yet specific carotid revascularization was only used during the chronic phase of the disease. Similarly, peripheral operation was ineffective in reducing the mortality rate in the setting of mesenteric (87%) and renal (50%) ischemia. Fifteen patients required either fenestration or graft replacement of the abdominal aorta for acute obstruction, rupture, or chronic aneurysm development. Thirty-eight patients (12%) demonstrated some degree of lower extremity ischemia, and one third of these required a direct approach on the abdominal aorta or iliofemoral segments to restore circulation. Selected patients with acute aortic dissection may require peripheral vascular operation in accordance with a treatment strategy that directs initial attention to the immediate life-threatening complications.

Aged↗
PubMed1988

Use of the gastroduodenal artery in right renal artery revascularization.

Of 15 patients having revascularization of the right renal artery with the use of the hepatic circulation from May 1984 through March 1987 at the Massachusetts General Hospital, eight patients had this accomplished with end-to-end anastomosis of the gastroduodenal artery and right renal artery. Operative indications were acute azotemic renal failure (three patients), poorly controlled renovascular hypertension (four patients), and staged repair of bilateral renal artery disease (one patient). All revascularizations were successful in restoring renal function or rendering hypertension manageable and were assessed by means of renal flow scans, celiac angiography, or return of function in those patients with a solitary, functioning kidney. All patients survived the operation with one late death caused by myocardial infarction after abdominal aortic aneurysm repair. The gastroduodenal artery may be used as the source for arterial inflow in revascularization of the right renal artery by end-to-end anastomosis in approximately 50% of instances, conferring the advantage of the use of only one anastomosis and obviating the long-term possibility of vein graft failure.

Anastomosis, Surgical↗
PubMed1987

Reoperation for aortofemoral graft limb occlusion: optimal methods and long-term results.

To determine optimal methods of reoperation, experience with 157 secondary procedures for unilateral aortofemoral graft limb occlusion in 110 patients during a 16-year period was reviewed. In earlier years, inflow was reestablished by direct replacement of the graft limb or entire graft (11%); more recently, graft limb thrombectomy has been used most frequently (68%) with equal success, durability, and less morbidity. Femorofemoral grafts from the patent contralateral graft limb were employed in 18% of patients, usually those in whom thrombectomy was not attempted. Thrombolytic therapy (3%) appears to offer little advantage, is time-consuming, and occasionally causes significant complications. In addition to reestablishment of inflow, most patients also required revision of the femoral anastomosis to improve profunda femoris runoff; this was usually best accomplished by short segmental extension of the graft limb to the more distal deep femoral artery. Concomitant femoropopliteal bypass was done in 32% of patients and is indicated when preoperative angiography or specific intraoperative findings suggest inadequate profunda femoris outflow. An aggressive approach to reoperation appeared justified by long-term results (mean follow-up 37 months). Despite the need for repetitive reoperation in 26% of patients (two to five reoperations), graft limb patency was ultimately maintained in 78% and limb salvage achieved in 67% of patients, with an operative mortality rate of only 1.9%.

Adult↗
PubMed1987

Superior sulcus lung tumors. Results of combined treatment (irradiation and radical resection).

Twenty-one patients underwent combined therapy (irradiation and radical resection) for a Pancoast tumor at the Massachusetts General Hospital between 1976 and 1985. All patients underwent en bloc removal of the apical chest wall and underlying lung. In addition four patients required subclavian artery resection, and in five patients a portion of the vertebral body was resected. There were three operative deaths. Median survival was 24 months and actuarial survival rate was 55% at 3 years and 27% at 5 years. Long-term palliation of pain was achieved in 72% of the patients. Involvement of the subclavian artery, vertebral body, or rib did not preclude long-term survival. Computed tomographic scanning in these patients is often indeterminate regarding invasion of chest wall structures but is more helpful than plain films alone. When compared to recent series in which irradiation alone was used, the combined approach appears to produce better results.

Actuarial Analysis↗
PubMed1986

Use of the splenic and hepatic arteries for renal revascularization.

During a 16-year period at the Massachusetts General Hospital 77 patients underwent 79 procedures (29 hepatorenal bypasses, 50 splenorenal arterial anastomoses) for treatment of renovascular hypertension, renal preservation, or both. The procedure was chosen primarily to avoid a diseased or scarred aorta in 41, to allow a staged approach to bilateral renal artery stenoses or multiple vascular lesions in 17, as a "lesser operation" for five poor-risk patients, for complex problems including trauma, mycotic aneurysm, aortic dissection, thoracoabdominal aneurysm, and renal artery aneurysm in five, and as the procedure of choice in 11 patients. The perioperative mortality rate was 6% for the 77 patients studied. No hepatic dysfunction was seen. Deterioration of renal function occurred on three occasions but only in patients with bilateral simultaneous repair. Cure or improvement of hypertension was achieved in 52 of 63 patients and renal function preserved or improved in 67 of 77 patients. Long-term functional results remain good during follow-up periods up to 14 years. Our experience indicates that use of the hepatic or splenic artery may provide a safe and largely successful alternative for renal revascularization in selected circumstances.

Follow-Up Studies↗
PubMed1985

Benign duodenocolic fistula.

Three cases of benign duodenocolic fistula are presented, and the diagnosis and treatment reviewed. Patients with benign duodenocolic fistulas usually complain of diarrhea, and occasionally nausea and feculent vomiting. Physical examinations are nonspecific, revealing wasting from the chronic diarrhea. Barium enemas are usually diagnostic. Therapy consists of excision of the fistula and repair of the duodenal and colonic defects.

Aged↗
PubMed1985

Innominate artery lesions: problems encountered and lessons learned.

Although unusual, innominate artery lesions may present challenging problems. To classify the wide spectrum of problems requiring operation and elucidate certain principles of management, a series of 71 patients undergoing operation for innominate artery problems over a 20-year period was reviewed retrospectively. Occlusive disease (37 patients) was most common, usually presenting with neurologic or ocular symptoms. Other lesions included innominate aneurysm (three), aortic dissection involving the innominate artery (three), traumatic injuries (five), tracheoinnominate fistula (10), anomalous origin or tortuosity causing tracheal compression (six), involvement in mediastinal tumor or scar (six), and thromboembolus (one). The type of operative repair and mortality rate varied with the nature of the lesion. Overall 38 patients underwent transsternal repair, whereas 12 had extrathoracic bypass, 16 resection and oversewing, and five a pexy procedure. For occlusive disease, direct repair via median sternotomy gave best long-term results with an acceptable mortality rate (3.4%). Shunting was not required. Extrathoracic grafting proved safe but less durable and should be reserved for high-risk patients or special circumstances.

Arterial Occlusive Diseases↗
PubMed1984

Changing times in surgical management of bronchopulmonary carcinoid tumor.

The bronchopulmonary carcinoid tumor occurs at all levels from trachea to lung periphery. It should be managed by conservatism in airway or lung resection. The long-term survival is excellent: 82% at 10 years in this series of 111 resected patients. The atypical carcinoid tumor (10% of this series) has a more ominous prognosis and requires special surgical attention. Six conceptual changes in the evolution of management of the tumor are presented (the "changing times").

Adolescent↗
PubMed1984

Host-artery weakness in the etiology of femoral anastomotic false aneurysms.

From 1970 through 1980, 47 patients developed a total of 69 false femoral artery aneurysms. Of these aneurysms, 58 occurred an average of 6.2 +/- 3.1 (SD) years after the original revascularization procedure. Ten of these aneurysms occurred once after initial repair and one occurred a second time. Endarterectomy was performed in almost one third of the arteries that later developed false aneurysms. Aneurysms developed in 18 endarterectomized arteries after performance of an anastomosis with a vein patch or Dacron graft. Infection was present in only one case. The suture material in the primary anastomosis was predominantly braided Dacron. Hypertension and bleeding were not commonly associated. Endarterectomy weakens anastomoses and is a factor in false aneurysm formation.

Aged↗
PubMed1982

Deep venous thrombophlebitis following aortoiliac reconstructive surgery.

One hundred patients undergoing elective aortic surgery were scanned prospectively for development of deep venous thrombosis (DVT). The incidence of DVT in this population was 13%. Eleven patients showed only calf vein thrombosis on venography, whereas two had occlusive iliofemoral thrombus. The correlation between venous Doppler ultrasound and venography was 80%. More importantly, Doppler examination correctly identified both patients with occlusive thrombus. Fibrinogen scanning was associated with a false-positive rate of 31%. Only one patient suffered a nonfatal pulmonary embolus. Fibrinogen scanning has an unacceptably high false-positive rate; however, Doppler ultrasound will identify significant occlusive thrombus without a high false-positive rate. The low incidence of pulmonary emboli does not warrant such definitive measures as prophylactic vena caval interruption.

Adult↗