Biomedical subjects
Publications and source records attributed to D B McConnell.
In an effort to reduce the rate of nontherapeutic celiotomy yet avoid the possibility of missed injuries, surgeons are evaluating protocols for nonoperative management of abdominal trauma. Discussion of this controversial issue includes specific approaches to the diagnosis and management of splenic injury, gunshot wounds, and stab wounds.
Seventy-six axillobifemoral grafts with externally supported polytetrafluoroethylene prostheses were performed since 1983. The indications for operation were absolute (aortic sepsis) in 20 (26%) patients and relative (excessive operative risk or technical difficulty) in 56 (74%) patients. The life-table primary patency for these operations at 4 years follow-up (mean follow-up, 2 years, 4 months) was 85%. We conclude that the patency results achieved in this patient series are sufficiently satisfactory to warrant use of axillobifemoral grafts in an expanded number of patients with high operative risk and need for bypass of aortoiliac occlusive disease.
Most arterial prosthetic graft infections can be prevented although a few will inevitably still occur. Maintaining a high index of suspicion for graft infection permits prompt diagnosis which provides the opportunity for early surgical management and improved potential for a good result. Aortic graft infection is best managed with extra-anatomical prosthetic bypass through clean tissue followed by graft excision. Results with this surgical approach are improving. Recently, authors advocating in situ grafting for graft enteric fistula as well as others recommending nonresectional therapy for localized prosthetic graft infections, have obtained encouraging results comparable to the best series of more standard excisional therapy. Because prosthetic graft infection remains a difficult surgical problem, any potentially useful management innovations warrant serious consideration and analysis with extended follow-up.
A 4-year experience with 249 consecutive carotid endarter-ectomies performed on 224 patients is reviewed for incidence of perioperative (30-day) myocardial infarction and early survival (mean follow-up, 21 months). Except in cases of unstable angina, coronary arterial disease was evaluated only by routine history, physical examination, and electrocardiogram. By these criteria, 73% of patients had evidence of coronary arterial disease. Patients underwent carotid endarterectomy after appropriate medical management and stabilization of coronary disease symptoms (angina and/or congestive heart failure). One (0.4%) fatal and nine (3.6%) nonfatal perioperative myocardial infarctions Early survival of patients with active symptoms of coronary disease who did not undergo coronary bypass was similar to those patients with preceding or subsequent coronary bypass. The results of this review suggest routine clinical evaluation for coronary arterial disease is sufficient in the large majority of cases prior to carotid endarterectomy. Considering the reported high mortality of coronary bypass among vascular surgical patients, it appears that an aggressive program screening for cardiac surgical candidates either by coronary arteriography or radionuclide studies prior to carotid endarterectomy is not warranted.
To determine if the surgical treatment of peptic ulcer disease within a Veterans Administration hospital has changed over the past decade, we compared two groups of patients. Group 1 (n = 104) had surgery between 1974 and 1977 and group 2 (n = 61) had surgery between 1984 and 1987. In group 1, 49 (47%) ulcer operations were performed for chronic symptoms, while in group 2, 11 (18%) were performed for nonemergent reasons. The remaining 55 (53%) patients in group 1 and 50 (82%) in group 2 had operations for complications of peptic ulcer. When expressed per 1000 admissions, the rates of operations for complications were similar (1.08 vs 1.1). The relative proportions of perforation, bleeding, or obstruction were similar for patients in the two groups, as was the American Society of Anesthesiologist's Physical Status rating (3.1 vs 3.2). The fitness score, a scale for assessing preoperative risk with 10 representing the greatest risk, was also similar (6.7 vs 6.8). An American Society of Anesthesiologist's Physical Status value of greater than 3 and a fitness score of greater than 6 indicate that these patients were at high risk with an expected operative mortality of greater than 25%. In fact, the mortalities in groups 1 and 2 for patients having emergency operations for complications were 29% and 30%, respectively. The marked reduction in elective ulcer operations observed in our institution may be due to several factors, including better nonoperative therapy (eg, histamine receptor antagonists), physician preference for nonoperative treatment of chronic ulcers, or a reduced incidence of chronic ulcer within our population. However, the number of emergency operations for complications of ulcer has remained constant. These complications occur in poor-risk patients with concomitant illness, and the operative mortality for these patients is high.
Five patients with infected abdominal aortoiliac aneurysms were treated. The diagnosis was made preoperatively based upon fever, leukocytosis, positive blood culture findings, and presence of an aneurysm in all five patients. Two patients had salmonella species, two had staphylococcus species, and one had bacteroides species cultured from the blood and aneurysm contents. All patients were treated with appropriate antibiotics and a single operative procedure consisting of preliminary extraanatomic bypass followed by complete aneurysm excision and posterior drainage of the retroperitoneum. There were no operative deaths and no instances of aortic stump disruption, persistent retroperitoneal sepsis, or graft thrombosis. All patients were alive and well on last follow-up 15 months to 5 years postoperatively.
Repair of limited cervical esophageal defects can now be accomplished safely with mucosa-lined flaps. Free jejunal grafts have demonstrated excellent durability and function for circumferential defects. The axial cheek flap and laryngeal flap have also shown excellent functional results for noncircumferential defects. In addition, all three of these procedures offer the advantage of immediate reconstruction. The size of the esophageal defect, the physical condition of the patient, and the rehabilitative goals are critical in patient selection.
Nineteen patients with a prosthetic infrarenal aortic graft and gastrointestinal bleeding were managed over a 7 year period. Graft-to-enteric fistula, identified in five patients, was the most common cause of bleeding. Other causes included bowel ischemia (four patients) and peptic ulcer disease (three patients). Clinical signs of infection, such as fever and leukocytosis, were common in patients with graft-to-enteric fistula and bowel ischemia. Most of these patients will benefit from a prompt evaluation and expedient operation.
The operative outcome of 97 consecutive nonruptured infrarenal aortic aneurysms is analyzed regarding clinically identifiable cardiac risk factors. Clinically evident coronary artery disease was present in 45 patients (46%). Operative mortality was 4% (four cardiac deaths) with an additional 4% nonfatal postoperative myocardial infarction rate. All cardiac complications occurred in patients with clinically evident coronary artery disease, while no mortality occurred in 52 patients lacking a preoperative history of myocardial infarction, congestive heart failure, or angina. Preoperative risk factors having a significant negative influence on outcome include a history of prior myocardial infarction and compensated congestive heart failure. Few patients with aneurysms who have clinical evidence of coronary artery disease are indicated for coronary arteriography and bypass prior to aneurysm repair. Furthermore, indications for invasive cardiac screening of the patient with an aneurysm who lacks cardiac symptoms are limited.
Our experience thus far indicates that the island cheek flap is a satisfactory reconstructive method for small but critical defects in the upper aerodigestive tract. The mucosal lining is an ideal replacement for the lining of the mouth, pharynx, and esophagus. Only a single stage procedure is required. The surgical technique is relatively simple and does not unnecessarily prolong an extensive operation for tumor resection. We have found the procedure to be reliable with no instances of flap loss or necrosis.
A 32 year retrospective review of 24 cases of gallstone ileus from the hospitals of Oregon Health Sciences University has been presented. Nineteen patients (79 percent) were female and 18 (75 percent) were more than 70 years of age. Fifty-four percent of the patients had a correct preoperative diagnosis that correlated well with the roentgenographic findings. Enterolithotomy was the most frequently employed operation, and cholecystoduodenal fistulas were positively identified in 61 percent of the patients. Most obstructions occurred in the distal ileum (48 percent). Wound infections occurred in six patients (26 percent), and there were three deaths for a mortality rate of 13 percent. Of note, the incidence of wound infections and mortality is found to be decreasing. This is related to the more frequent use of prophylactic antibiotics. The controversy regarding performing an enterolithotomy alone versus a one stage procedure has been reviewed and several interesting and atypical cases have been briefly discussed.
A total of 51 patients with pyriform sinus carcinoma were treated surgically. Fifty had pharyngolaryngectomy and radical neck dissection and 1 had a pharyngolaryngectomy. The surgical mortality was zero. No patients were lost to follow-up and all were followed for a minimum of 2 years. Stage IV patients had a 2 year survival rate of 15 percent and stage III patients, a 45 percent rate. Eighty-four percent of radical neck specimens contained involved nodes. The 2 year survival rates correlated with the number of pathologically involved nodes were as follows: 50 percent for those with zero to one node, 31 percent for two to three nodes, and 16 percent for four or more nodes. Perioperative radiotherapy increased the survival rate in those patients with zero to three involved nodes (47 percent survival rate with radiotherapy versus 25 percent without radiotherapy). Tumor recurrence was most frequent at the primary site (32 percent) and directly affected survival and control of disease elsewhere. Pyriform sinus carcinoma often presents with advanced local and nodal disease. Local control is essential, and adequate resection may require a cervical esophagectomy. Survival may be enhanced by the addition of radiotherapy in those patients with minimal nodal involvement.
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This report of 25 patients with prosthetic graft infection has compared the diagnosis, management, and outcome in 14 patients with infected aortic grafts with 11 patients with infected peripheral grafts (two axillofemorofemoral, five femorofemoral, five femoropopliteal, and one femoral interposition). Peripheral graft infection had a significantly shorter interval to diagnosis compared with aortic graft infection. Total graft removal combined with either autogenous revascularization or extraanatomic bypass using prosthetic graft was performed in all 14 patients with infected aortic grafts. Management of peripheral graft infection consisted of total graft removal in eight patients (four with autogenous revascularization and two with amputation) and partial graft removal in three patients (two with amputation). Mortality and amputation rates for infected aortic grafts were 43 percent and 25 percent, respectively compared with 36 percent and 27 percent for infected peripheral grafts. Recommendations for management of the infected aortic prosthetic graft include total graft removal, but methods and timing of revascularization are dependent on the specific features of the individual case. However, preferred management for the infected peripheral prosthetic graft includes total graft removal and, if indicated, revascularization using autogenous tissue.
Seven patients had reconstruction with an island cheek flap based on the facial vein and artery. The flap carries a swatch of buccal mucosa that can be rotated inferiorly as far as the superior mediastinum and superiorly to the oral cavity. Five patients had repair of cervical esophageal strictures and fistulas. In four, results were very successful. One patient had diminished but persistent dysphagia which was shown to be secondary to a carcinomatous polyneuropathy; however, he had complete resolution of aspiration after correction of his mechanical obstruction and tracheoesophageal fistula. Morbidity was minimal. Parotiditis developed in one patient who had Stensen's duct ligated. Minor numbness of the lip and a single case of Frey's syndrome were also observed. In another patient, reconstruction of the floor of the mouth preserved normal speech and swallowing. Finally, a permanent speech fistula was also created but was substantially taken down because of functional dissatisfaction. Other potential applications need to be explored.
After reviewing 21 patients who have had percutaneous abdominal abscess drainage, we believe that the procedure should be considered for those abscesses that are unilocular without septations, with safe access being a key variable dictating the use of percutaneous abdominal abscess drainage rather than surgery. A computerized tomographic scan of the abdomen should be employed at some stage of the percutaneous abdominal abscess drainage procedure to facilitate safe access to the abscess and to distinguish a synchronous abscess where present. In addition, we believe that percutaneous abdominal abscess drainage should be considered for postsurgical abscesses only and not those that are spontaneous in nature or where the original abnormality cannot be accurately surmised. With regard to catheter management, frequent irrigation of the catheter must be carried out at least every 4 to 6 hours, with high levels of antibiotics present in the blood before irrigation. This must be done to obviate the most frequent and potentially lethal complication of the procedure, namely sepsis. Percutaneous abdominal abscess drainage, although safe for the most part, is capable of inducing considerable morbidity. Our data suggest that percutaneous abdominal abscess drainage is not as efficacious as previous reports have suggested. Traditional surgical drainage techniques are best utilized for those abscesses that are multiple, highly viscous, inaccessible, spontaneous, or unresponsive to percutaneous abdominal abscess drainage.
We used microvascular anastomoses to transpose free pedicle jejunal mucosal patch grafts in seven patients. The procedure has been particularly helpful in rebuilding large intra-oral mucosal defects created by extensive resections for advanced carcinomas. Some of the benefits of this technique have included a one-stage procedure, which requires two to three weeks for healing; abundant donor tissue with characteristics similar to oral mucosa; near-normal facial appearance; and preservation of maximum tongue function. An unexpected benefit has been relief of annoying xerostomia by the jejunal mucous secretion. The most severe complication, which resulted in one death, was the excessive oral jejunal mucous secretion in the early postoperative period. It led to significant aspiration pneumonitis. To prevent this problem, we recommend a routine tracheostomy combined with rigorous pulmonary care whenever a jejunal patch graft is used.