Duodenal perforation: the laparoscopic perspective.
Explore the source record for details and available documents.
Abdomen, Acute↗
Biomedical subjects
B Sussman
Publications and source records attributed to B Sussman.
Prostate-specific antigen-producing cells in the bone marrow of a patient with early-stage prostate cancer.
This report describes a clinical case that supports the hypothesis that occult bone marrow disease may exist even in early-stage and low prostate-specific antigen (less than 10 ng/mL) prostate cancer. The concept of adding androgen suppression to definitive local therapy in these patients is discussed.
Aged↗
Clinical experience with everted cervical vein as patch material after carotid endarterectomy.
PURPOSE: The aim of this study was to evaluate the clinical efficacy of everted cervical veins used as patches after carotid endarterectomy. METHODS: A prospective nonrandomized comparative analysis was performed on patients with either everted cervical veins or saphenous veins as patches after carotid endarterectomy. Two hundred ninety-six patients underwent 329 carotid endarterectomies during an 8 1/2-year period (1987 to 1995). Saphenous vein patches were used in 125 (38%) cases and everted cervical veins in 167 (51%). These two groups were compared clinically and by sonographic surveillance. The mean follow-up of patients in this study was 27 +/- 11 months. RESULTS: No significant differences were noted regarding postoperative morbid events between the everted cervical and saphenous vein patch groups. Even at 5 years the percentage of patients without stroke for both groups exceeded 95%. Duplex surveillance studies also showed comparable percentages of recurrent moderate (50% to 69%) and severe (70% to 99%) stenosis, 5.6% and 6.9%, respectively, for everted cervical vein and 5.4% and 6.5%, respectively, for saphenous vein. Cumulative recurrent stenosis-free rates at 5 and 6 years exceeded 82% for each of the patch study groups. CONCLUSIONS: Based on the results of this study everted cervical veins are useful adjuncts to carotid endarterectomy, when patch angioplasty is necessary or desirable. Their performance is comparable to that of saphenous veins. Cervical veins are usually available, even when the saphenous vein is absent or inadequate. In addition, good saphenous veins can be spared and lower extremity excisions avoided.
Aged↗
Laparoscopic management of iatrogenic colon perforation.
Explore the source record for details and available documents.
Adult↗
Laparoscopic management of acute small-bowel obstruction.
BACKGROUND: A retrospective review is given of the authors' experience with a consecutive series of acute small-bowel obstruction unresponsive to medical management. METHODS: There were 33 exploratory laparoscopies. The etiology was accurately diagnosed in 100% of the cases. Twenty-five (76%) were secondary to postoperative adhesions, of which 18 (72%) were successfully treated by laparoscopic lysis of adhesions. Minilaparotomy was needed to treat iatrogenic perforation (two), gangrenous bowel (one), and Meckel's diverticulectomy (one). Formal laparotomy was utilized for small-bowel resection (two), malignant adhesions (two), and intolerance of pneumoperitoneum (one). Four cases of incarcerated hernias were treated by conventional herniorrhaphy. RESULTS: Overall, 67% of our cases were spared formal laparotomy. CONCLUSION: We conclude that laparoscopy is an excellent diagnostic modality in acute small-bowel obstruction, the majority of which can be simultaneously managed laparoscopically. Laparotomy should be reserved for malignant adhesions, surgical misadventure, or when the pathology dictates.
Acute Disease↗
Results of a prospective, randomized trial of surgery versus thrombolysis for occluded lower extremity bypass grafts.
PURPOSE: The purpose of this study was to prospectively evaluate the treatment of patients with occluded lower extremity bypass grafts, comparing surgical revascularization with catheter-directed thrombolysis. MATERIALS AND METHODS: One hundred twenty-four patients (68% male and 32% female) with lower limb bypass graft occlusion (46 autogenous and 78 prosthetic) were prospectively randomized to surgery (n = 46) or intra-arterial catheter-directed thrombolysis (n = 78) with recombinant tissue plasminogen activator (rt-PA) 0.1 mg/kg/h modified to 0.05 mg/kg/h for up to 12 hours, or urokinase (UK) 250,000 U bolus followed by 4,000 U/min for 4 hours, then 2,000 U/min for up to 36 hours. A composite clinical outcome including death, amputation, ongoing/recurrent ischemia, and major morbidity was analyzed on an intent-to-treat basis at 30 days and 1 year. RESULTS: The average duration of graft occlusion was 34.0 days, with 58 (48%) presenting with acute ischemia (0 to 14 days) and 64 (52%) with chronic ischemia (> 14 days). Thirty-nine percent randomized to lysis failed catheter placement and required surgical revascularization. Overall, there was a better composite clinical outcome at 30 days (P = 0.023) and 1 year (P = 0.04) in the surgical group compared with lysis, due predominately to a reduction in ongoing/recurrent ischemia, most notable in autogenous grafts. However, following successful catheter placement, patency was restored by lysis in 84%, and 42% had a major reduction in their planned operation. One-year results of successful lysis compared favorably with the best surgical procedure, which was new graft placement. Acutely ischemic patients (0 to 14 days) randomized to lysis demonstrated a trend toward a lower major amputation rate at 30 days (P = 0.074) and significantly at 1 year (P = 0.026) compared with surgical patients, while those with > 14 days ischemia showed no difference in limb salvage but higher ongoing/recurrent ischemia in lytic patients (P < 0.001). Patients with occluded prosthetic grafts had greater major morbidity than did those with occluded autogenous grafts (P < 0.02). CONCLUSIONS: Proper catheter positioning currently limits the potential of catheter-directed thrombolysis for lower extremity bypass graft occlusion. Patients with graft occlusion > 14 days have a significantly better outcome when treated surgically, with a new bypass being the best surgical option. However, in patients with acute limb ischemia (< 14 days) successful thrombolysis of occluded lower extremity bypass grafts improves limb salvage and reduces the magnitude of the planned surgical procedure. Patients with occluded prosthetic grafts suffer more major morbid events compared with occluded autogenous grafts.
Female↗
Improved method to create the common ostium variant of the distal arteriovenous fistula for enhancing crural prosthetic graft patency.
PURPOSE: Successful use of the distal adjunctive arteriovenous fistula (dAVF) for the enhancement of prosthetic graft patency rates in the crural position is critically dependent on the qualitative and quantitative aspects of the arterial and venous runoff. Precise technical performance of the fistula is equally vital to secure optimal results. The purpose of this study was to determine current prosthetic graft patency and limb salvage rates using a modified version of the common ostium dAVF. METHODS: The standard method to create the common ostium variant of dAVF has been modified to improve apposition of the "otomy" sites of the artery and vein, avoid twisting and stenosis by terminating the fistula suture line at the artery-vein junctures, reshaping the ovoid ostium to a rectangular shape, and finally, use of multiple interrupted heel-toe sutures. RESULTS: Since 1979 we have created 290 fistulas in 281 patients who required leg revascularization procedures. In different time periods we have documented improving graft patency and limb salvage rates. Fistula patency, reflected by annual attrition rates of 13% to 26% per year, continues as a challenge for long-term results. Current 3-year secondary cumulative graft patency and limb salvage rates by life table analysis are 61% and 74%, respectively. The conduit material may play a role with regard to steal phenomena and the need for banding techniques. CONCLUSION: Configuration of the adjunctive dAVF may impact on prosthetic graft patency in the crural position. In addition, the type of graft material used for bypass may be instrumental in preventing or precipitating the steal phenomenon. These issues require further study to better understand flow dynamics, patterns of intimal hyperplasia, and blood distribution as a function of conduit material and impedance of the arterial and venous runoff.
Adult↗
Experience with a new valvulotome for lower-extremity revascularization procedures by the in situ method.
Between November 1990 and November 1992, 50 consecutive cases requiring lower-extremity revascularization by the in situ method were compared with regard to use of two different valve cutters, the Hall valvulotome and the Insitucat. There were no amputations in patients with patent grafts, nor were any infections or false aneurysms noted during the course of this study. In the Insitucat group (n = 25), primary patency was achieved in 19 cases. Five of the six graft failures underwent additional procedures of which three remained patent, adding to the secondary patency rate (22 of 25). The greatest problem with regard to maintaining primary graft patency was that of missed or retained valves, but the incidence of this problem decreased during the course of this study as experience was gained with the catheter in conjunction with angioscopy. Experience with the Insitucat valvulotome has demonstrated its efficacy, though enhanced by monitoring the results with angioscopy. The development and discovery of focal stenotic areas and retained valves by surveillance sonography have resulted in enhanced (assisted) primary graft patency rates. The incidence of these problems appears to be comparable with that occurring with other means of producing valvular incompetence for an in situ reconstruction where valvulotomes of similar design are employed. This was confirmed by comparative analysis with another group of 25 in situ vein bypasses performed during the same time period but during the Hall valvulotome.
Aged↗
Pneumatosis intestinalis in patients with Crohn's disease.
The prevalence, predictors, and significance of pneumatosis were determined in 50 patients with Crohn's disease who had abdominal CT scans to rule out abscess. The presence or absence of six CT descriptors and 17 clinical descriptors was documented. CT scans of a control group of 50 subjects without inflammatory bowel disease were also examined. Data was analyzed by two-sample t tests and Fisher's exact test. Pneumatosis was found in six of 50 patients with Crohn's disease and in none of the controls. Corticosteroid treatment was the single clinical variable relating significantly (P = 0.025) to pneumatosis, although trends toward absence of resection, short duration of illness, and more severe anemia were also evident in this group. This study suggests that the presence of pneumatosis alone does not dictate a specific course of treatment, but when pneumatosis is present, careful monitoring is required and therapy is based on the overall clinical picture.
Adult↗
Interval gangrene of the lower extremity: a complication of vascular surgery.
Interval gangrene, segmental ischemic necrosis proximal to a functioning distal anastomosis, is a rare complication after successful peripheral vascular reconstruction. Previous reports have demonstrated the gravity of this event in that major limb amputation was required in all cases. Two cases are presented to emphasize the need for maintaining segmental collateral circulation after successful distal extremity bypass. Despite a satisfactory result after distal (inframalleolar) bypass of a popliteal aneurysm, one patient had progressive ischemic gangrene of the upper leg and eventually required amputation. The contralateral limb was successfully managed by distal ligation of the superficial femoral artery, which maintained collateral flow from the proximal superficial femoral artery to the knee and leg. The second patient required a microvascular free flap to replace tissue loss and provide vascular graft coverage after initial multiple bypass failures and a final successful remote reconstruction to the dorsal artery of the foot that excluded the popliteal-crural collateral network. Patients with inadequate collateral circulation or disruption of the profundus or geniculate collateral pathways may require revascularization of sequential vascular beds. Recognition of the potential for interval gangrene is essential since the likelihood of its occurrence will increase in proportion to the number of distal bypasses being performed for limb salvage. Although adjunctive procedures will not completely eliminate the possibility of interval gangrene, awareness of this phenomenon with attention to the segmental collateral circulation can decrease the incidence of its occurrence.
Adult↗
Infrapopliteal prosthetic graft patency by use of the distal adjunctive arteriovenous fistula.
From November 1979 through December 1989, 210 distal arteriovenous fistulas were constructed as adjuncts to tibial and peroneal vascular reconstructive procedures in 203 patients threatened with limb loss. Two-year cumulative patency rates were calculated by grouping patients on the basis of changing indications in sequential time periods: group 1 (n = 61): 1979 to 1983, 18%; group 2 (n = 80): 1983 to 1986, 33%; group 3 (n = 69): 1986 to 1989, 44%. Although the therapeutic results observed in these groups are not statistically comparable, they show a perceptible trend. Postoperative arteriography showed that flow is prograde in the distal vessels beyond the distal arteriovenous fistula. Graft surveillance by duplex ultrasonography also confirmed that flow in the distal arteries is prograde and that "steal" does not occur. Peak systolic velocity (174 +/- 38 cm/sec) and mean velocity (92 +/- 23) flow rates are increased in grafts with patent distal arteriovenous fistulas compared to those bypasses with closed distal arteriovenous fistulas (p less than 0.01). There were no differences in the flow measurements for the arteries beyond the distal anastomoses and distal arteriovenous fistulas, confirming the prograde nature of the distal flow. In 22 patients analysis of graft and fistula patency by duplex sonography showed that one fourth of all grafts were patent without fistulas at 1 and 2 years after operation. Alternatively, 68% of patent grafts at 1 year had patent fistulas and 58% had patent fistulas at 2 years. We conclude that the distal arteriovenous fistula will increase graft flow and simultaneously prevent distal arterial overload without causing "steal." This technique should be considered whenever a prosthetic graft is necessary for crural reconstruction and only in selected instances of revascularization with autologous veins.
Adult↗
Transmetatarsal amputation: the role of adjunctive revascularization.
Over a 12-year period, 160 transmetatarsal amputations were performed in patients with peripheral vascular occlusive disease. The following groups were defined: group 1 - nonreconstructable disease (n = 40); group 2 - transmetatarsal amputation in conjunction with distal revascularization (n = 99); group 3 - reconstructable disease but transmetatarsal amputation performed without simultaneous revascularization (n = 21). There were nine early deaths in the entire series, for an operative mortality rate of 5.6%. The lowest rate of transmetatarsal amputation healing (24%) occurred in group 1. An 86% healing rate was achieved in group 3, but in seven cases (33%) some type of revascularization was required within 3 months of the amputation. In group 2 the healing rate was 62% but reached 83% where the bypass remained patent for at least 3 months after the amputation. Long-term patency rates also affected healing. Healing was not influenced by the number of local procedures (single vs multiple). The presence of severe infection or extensive necrosis necessitated open transmetatarsal amputation in 89 cases; the remaining 71 amputations involved primary closure. Since many patients were treated at a time when diagnostic modalities as well as the operative indications and techniques differed somewhat from the current practice, much of the information regarding group I patients in particular should be considered as a negative historical control and any conclusion from our data should be adjusted accordingly. Healing after amputation at the transmetatarsal level can be expected in the majority of instances in which revascularization can be performed with predictable patency, even when the standard criteria for performing such amputations are liberalized.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Epidural anesthesia as an adjunct to retroperitoneal aortic surgery.
Recent developments in vascular surgery suggest that the retroperitoneal approach to the aorta and the use of epidural anesthesia for lower limb revascularization are associated with decreased morbidity and shorter hospital stays. By combining these principles, we sought to determine if retroperitoneal aortic surgery could be performed under epidural anesthesia and if this might be advantageous. Over a 16-month period, 57 patients underwent aortic surgery via the retroperitoneal (n = 33) or transperitoneal (n = 24) approach. In the former, epidural anesthesia was employed in 10 patients, general anesthesia in 3, and combined epidural anesthesia and general anesthesia in the remaining 20. In the transperitoneal group, general anesthesia was employed in 21 patients and combined epidural anesthesia and general anesthesia in 3. Both groups were similar in age and gender, but risk factors were predominant in the retroperitoneal group. With the exception of one death due to aspiration, there were no significant differences between the transperitoneal and retroperitoneal groups with respect to overall morbidity, pulmonary complications, and length of stay in the intensive care unit and hospital. Despite these findings, we favor the combination of epidural and general anesthesia for retroperitoneal aortic surgery. Morbidity was significantly decreased (p less than 0.05) in low-risk retroperitoneal patients when combined epidural anesthesia and general anesthesia were employed.
Adult↗
Atheroemboli to the lower urinary tract: a marker of atherosclerotic vascular disease--a case report.
Atheroemboli to the lower genitourinary tract may serve as a marker for disseminated atheroembolic disease, a highly lethal condition. A case presentation and review of our institional experience is presented.
Aged↗
Everted cervical vein for carotid patch angioplasty.
Because of the theoretic benefits of autologous vein we undertook an investigation to evaluate cervical veins (facial, external jugular) as patch material after carotid endarterectomy. A device that stimulated both circumferential fixation by sutures and radial tension exerted on in vivo patches was constructed to measure burst strength of tissue. Mean bursting pressure for groin saphenous vein (n = 10) was 94.5 +/- 15.1 pounds per square inch (psi), 75.5 +/- 8.9 psi for ankle saphenous vein (n = 10), 83.3 +/- 14.5 psi for everted (double layer) cervical vein (n = 5) and 10 +/- 3.3 psi for single layer cervical vein (n = 5). No significant differences between saphenous vein at any level and everted (double layer) cervical vein, but all were significantly different from single layer cervical vein (p less than 0.05). From June 1987 through November 1989, 19 patients underwent 21 carotid endarterectomies complemented with adjunctive everted cervical vein patch angioplasty. Indications for surgery were asymptomatic stenosis (53%), transient ischemic attack (29%), and cerebrovascular accident with recovery (18%). All patients were studied after surgery with duplex scanning. Asymptomatic recurrent stenosis was observed in one patient. Transient hypoglossal nerve dysfunction occurred in one other patient. One postoperative death occurred as a result of massive aspiration. These results indicate that everted cervical vein is comparable to the saphenous vein in resistance to bursting and can yield similar results as patch material after carotid endarterectomy. Accordingly, saphenous vein can be spared and lower extremity incisions avoided.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Cutaneous malignant melanoma.
From January 1973 to December 1985, 136 patients with primary cutaneous malignant melanoma were treated at Englewood Hospital. Pathologic types, methods of treatment, and results are discussed and a comparison of results is made with other institutions.
Adult↗
A decade of experience with the glutaraldehyde-tanned human umbilical cord vein graft for revascularization of the lower limb.
Between October 1975 and November 1985, 907 lower limb bypasses were constructed in 715 patients (799 limbs) with glutaraldehyde-stabilized umbilical veins (UV-G) used as the predominant, or sole, graft material. Each reconstruction was classified in one of eight categories depending on the site of the distal anastomosis: above- and below-knee popliteal, anterior and posterior tibial, peroneal, trifurcation, sequential, and crural (tibial or peroneal) bypasses with adjunctive distal arteriovenous fistulas. Primary and secondary cumulative graft patency rates were determined for each category as well as cumulative actual palliation that combines end points of graft failure, amputation, and death. Half-life patencies for popliteal, tibial, and peroneal bypasses were 6.5, 2.3, and 1.7 years, respectively. Perioperative graft thrombosis occurred in 11% of popliteal reconstructions compared with 22% for the crural group. Nonocclusive graft failure caused by infection, aneurysm, or progressive foot gangrene occurred in 87 grafts (8%). The overall infection rate was 4.3%. Anastomotic aneurysms (1.4%) and strictures (2.1%) occurred infrequently as isolated phenomena. The incidence of graft dilatation and aneurysms assumed significant proportion after 5 years (36% aneurysms and 21% dilation); the diagnosis was particularly facilitated by B-mode imaging. Nevertheless, the overall clinical impact of graft degradation remained minimal (6% after 5 years). Twenty-two of 26 graft aneurysms were excised with successful graft replacement achieved in 10. During this 10-year period, our attitudes did change with regard to the indication for UV-Gs in relation to the maturation of infrapopliteal reconstructive surgery, appreciation of the superior results attainable with in situ saphenous vein, recognition of morphologic changes in long-term UV-G implants, and the growing documentation of poor results with polytetrafluorethylene in the crural position. We believe that UV-G is an acceptable alternative to the absent or deficient autologous vein, particularly in patients with limited life expectancy and where expediency may be a critical factor.
Adolescent↗
Primary and adjunctive intra-arterial digital subtraction arteriography of the lower extremities.
Standard contrast arteriography (SCA) and intra-arterial digital subtraction arteriography (DSA) were performed during a 26-month period in 459 cases. The DSA group consisted of 22 aortoiliac studies, 66 crural-pedal arch studies, and 227 combinations. In addition, postoperative DSA was performed in 42 patients to evaluate graft patency, morphology, and inflow and runoff circulations. There were no significant differences in the quality of the preoperative aortoiliac studies performed by either SCA or DSA although, in select cases, one or the other of these techniques resulted in a superior study. Distal crural-pedal arch visualization was enhanced with DSA compared with SCA (85% vs. 65%) but when both were compared with their corresponding intraoperative completion arteriograms, the interpretive error rates resulted in comparable accuracies, false positive and negative rates, and predictive values. The likelihood of achieving graft patency in patients who have unsatisfactory preoperative visualization of the distal circulation by DSA is reasonable (11 of 27 patients) but inferior to the number obtained when there is adequate DSA visualization (40 of 53 patients). We conclude that DSA is a valuable adjunct to preoperative SCA but should not be used as the sole criterion for the assessment of operability for limb salvage. Intraoperative prereconstruction arteriography or direct surgical exploration of the crural arteries in patients with inadequate preoperative visualization will result in graft patency in a significant percentage of cases. Intra-arterial DSA for postoperative evaluation of lower limb bypass adds another dimension to analysis of graft structure and status of the host circulatory beds and also provides a method for accurate interpretation of postoperative data.
Angiography↗