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Biomedical subjects

J M Porter

Publications and source records attributed to J M Porter.

At least 19 recordsLinked to original sources
PubMed1992

Neurologic deficits following noncarotid vascular surgery.

Neurologic events following noncarotid vascular surgery (NCVS) are considered unpredictable. To test this hypothesis, we reviewed our vascular registry for a 3-year period and identified all patients with new postoperative focal neurologic events (stroke, hemispheric transient ischemic attack [TIA]) within 2 weeks of a category I or II vascular procedure as defined by the American Board of Surgery, exclusive of carotid surgery and arterial trauma. Thirteen of 1,390 NCVS procedures (0.9%) in 13 patients were associated with focal neurologic events. There were 2 TIAs, 10 anterior circulation strokes, and 1 posterior circulation stroke. Twenty-seven percent of strokes were fatal. The neurologic deficit developed in the immediate postoperative period in 31%, more than 4 hours but less than 72 hours postoperatively in 54%, and within 3 to 14 days postoperatively in 15%. Patients with anterior circulation events (group A, n = 12) were compared for variables potentially influencing postoperative stroke with case controls who were selected using a table of random numbers (group B, n = 12). Controls were derived from a pool of all category I or II NCVS procedures recorded in our vascular registry sequentially during the same time period and who were without new neurologic deficits postoperatively. Using Fisher's exact test, comparisons between groups A and B revealed that new anterior circulation neurologic events in vascular surgical patients tended to be associated with intra-abdominal procedures (p less than 0.05), perioperative hypotension (p less than 0.05), and the presence of a greater than or equal to 50% internal carotid artery stenosis ipsilateral to the neurologic event (p less than 0.001). Such information may prove useful in the management of selected patients prior to arterial reconstruction and in operated NCVS patients with postoperative neurologic events.

Aged↗
PubMed1992

The incidence of perioperative myocardial infarction in general vascular surgery.

In a 1-year period all patients undergoing general vascular surgery (491 patients, 534 procedures) underwent monitoring by creatine phosphokinase isoenzymes and electrocardiograms (ECG) to detect perioperative myocardial infarction. Only those patients with severe symptomatic coronary artery disease (31 patients, 5.8%) characterized by unstable angina pectoris, uncontrolled arrhythmia, or severe congestive heart failure had any testing for coronary artery disease beyond history, physical examination, and ECG. Only three patients (0.5%) had prophylactic coronary artery bypass performed before general vascular procedures. Twenty-one (3.9%) myocardial infarctions (five asymptomatic, detected by enzymes only, and 16 symptomatic, four of which were fatal) were associated with the 534 procedures (aorta 105, carotid 87, infrainguinal bypass 207, extraanatomic 51, other 84). Eight noncardiac perioperative deaths occurred. All operative deaths (12 of 534, 2.2%) including all four fatal myocardial infarctions occurred associated with surgery on an urgent or emergency basis (12 of 249 procedures, urgent/emergent operative mortality rate 4.8%). No operative deaths and no fatal myocardial infarctions associated with the 285 elective procedures occurred. Nine of the 17 nonfatal myocardial infarctions (53%) also occurred after urgent/emergent procedures. The rate of perioperative myocardial infarctions (eight of 285, 2.8%) after elective surgery in this patient series is no different from that reported by multiple recent authors advocating widespread screening for and prophylactic treatment of coronary artery disease before general vascular surgery. Our experience confirms the therapeutic approach that expensive and invasive coronary screening programs in patients to undergo vascular operations should be limited to carefully selected patients with severely symptomatic coronary disease.

Adult↗
PubMed1992

Surgical management of severe acute lower extremity ischemia.

Seventy-four patients (70 men [95%], 4 women [5%], mean age, 63 years) with severe, acute lower limb ischemia (acute clinical deterioration and absent pedal Doppler signals) caused by either arterial thrombosis (n = 68) or embolism (n = 6) underwent urgent surgical management consisting of operative revascularization with or without amputation in 67 patients (91%) and primary amputation alone in 7 patients (9%). Sixty-one patients (82%) had severely threatened limb viability, and 13 (18%) had major irreversible ischemic limb changes at presentation. Eighty-six percent of patients were initially anticoagulated with heparin. Seventy percent underwent preoperative angiography. Surgical revascularization included 42 inflow and 20 outflow arterial reconstructions and 9 thrombectomy or embolectomy procedures. Mean follow-up was 17 months (range, 0 to 64). Life-table primary patency at 36 months for arterial reconstructions was 81% for inflow and 78% for outflow procedures. Cumulative limb salvage was 70% at 1 month and 68% at 36 months. Patient survival was 85% at 1 month and 51% at 36 months. No death was directly attributable to complications related to limb reperfusion, and no patient required dialysis for myoglobinuria. We conclude that management of severe, acute lower limb ischemia with early amputation of nonviable limbs and heparinization, angiography, and prompt operative revascularization for threatened but viable extremities minimizes morbidity and mortality rates, while maximizing limb salvage. These results may be useful for comparison with comparable groups of patients treated with thrombolytic or endovascular modalities.

Acute Disease↗
PubMed1992

Teaching plastic surgery to medical students.

A plastic surgery syllabus for third-year medical students is described. It is intended for a teaching programme in which plastic surgery is integrated into the surgical teaching on the same basis as the other surgical specialties. The syllabus was designed to concentrate on aspects of plastic surgery relevant to the needs of undergraduates. An audit of the teaching showed that the students were readily interested and considered the teaching to be relevant to their examinations and to their future as doctors. A survey of all plastic surgery centres in the British Isles showed that similar teaching was being undertaken in 11 centres out of 51.

Clinical Competence↗
PubMed1992

Upper extremity arterial bypass distal to the wrist.

Seventeen arterial bypass procedures distal to the wrist have been performed in 13 men and two women at the Oregon Health Sciences University during the past 9 years. Ten patients had traumatic true or false aneurysms of the ulnar artery with digital embolization. Five patients with end-stage renal disease had severe hand and finger ischemia manifested by rest pain or digital ulceration resulting from widespread forearm and hand arterial occlusions. Patients with aneurysms of the ulnar artery underwent excision and reversed autogenous vein grafting (n = 11) from the distal ulnar artery in the forearm to the superficial palmar arch. All the patients with end-stage renal disease had severe occlusive disease of the forearm and hand arteries and underwent a variety of procedures including radial-radial bypass (n = 2), ulnar-ulnar bypass (n = 2), radial-radial bypass with takedown of a Brescia-Cimino fistula (n = 1), and brachial-radial bypass (n = 1). High-quality upper extremity and magnification hand arteriography was essential for operative planning and was available on all patients. Distal saphenous vein from the ankle or foot was the graft source in 16 procedures and basilic vein the source in one procedure. All operations were performed with headlight illumination, optical loupes, fine sutures, and microvascular instruments. There were no operative deaths or major complications. The mean follow-up period was 14 months. Of the 17 grafts, 16 remained patent by clinical and vascular lab criteria. The single occlusion occurred in an ulnar aneurysm bypass and was accompanied only by mild intolerance to cold.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1992

Carcinoid tumor of the gallbladder: laparoscopic resection and review of the literature.

A 75-year-old woman with mild elevation of liver function test results was found to have an asymptomatic mass localized to the gallbladder by computed tomographic scan and ultrasonography. Endoscopic retrograde cholangiopancreatography revealed a fixed 2 x 4 cm filling defect in the gallbladder wall, consistent with a gallbladder neoplasm. The gallbladder and intramural neoplasm were excised successfully by use of uncomplicated laparoscopic cholecystectomy. Pathologic analysis revealed a carcinoid tumor of the gallbladder. All previously reported gallbladder carcinoid tumors in the Western literature are reviewed. Laparoscopic cholecystectomy has potential for application for the treatment of selected gallbladder neoplasms, with special preoperative assessment and intraoperative considerations being important.

Aged↗
PubMed1992

A prospective audit of regional anaesthesia for hand surgery.

A prospective audit has been carried out of 153 consecutive regional anaesthetics for hand surgery, using intravenous regional anaesthesia (IVRA), axillary block or multiple peripheral nerve blocks in the upper limb. Surgery was carried out successfully in 147 patients. Apart from two patients, who complained of paraesthesia after regional nerve blocks, there were no side-effects. A total of 13 patients said that they would have preferred a general anaesthetic. Regional anaesthesia was found to be suitable for use by members of the surgical staff, but success was only assured by meticulous attention to detail and by careful safety precautions. Regional anaesthesia should not be attempted by inexperienced, unsupervised hand surgeons.

Adolescent↗
PubMed1992

Accuracy of lower extremity arterial duplex mapping.

We performed lower extremity arterial duplex mapping from the aortic bifurcation to the ankle in 150 consecutive patients evaluated for aortic and lower extremity arterial reconstruction and compared lower extremity arterial duplex mapping in a blinded fashion to angiography. On the basis of history, physical examination, and four-cuff segmental Doppler pressures individual lower extremities were classified as normal, isolated aortoiliac disease, infrainguinal disease, and multilevel inflow and outflow disease. For vessels proximal to the tibial arteries, lower extremity arterial duplex mapping was analyzed for its ability to insonate individual arterial segments, detect a 50% or greater stenosis, and distinguish stenosis from occlusion. In the tibial arteries lower extremity arterial duplex mapping was evaluated for its ability to visualize tibial vessels and to predict interruption of tibial artery patency from origin to ankle. Lower extremity arterial duplex mapping visualized 99% of arterial segments proximal to the tibial vessels, with overall sensitivities for detecting a 50% or greater lesion ranging from 89% in the iliac vessels to 67% at the popliteal artery. Stenosis was successfully distinguished from occlusion in 98% of cases. In the tibial vessels lower extremity arterial duplex mapping was better at visualizing anterior tibial and posterior tibial artery segments (94% and 96%) than peroneal artery segments (83%), (p less than 0.001). Overall sensitivities for predicting interruption of tibial artery patency were 90% for the anterior tibial, 90% for the posterior tibial, and 82% for the peroneal. Clinical disease category did not influence in a major way the accuracy of lower extremity arterial duplex mapping in either above-knee or below-knee vessels.

Aged↗
PubMed1991

Limb salvage vs amputation for critical ischemia. The role of vascular surgery.

Since 1980, 498 patients with 627 critically ischemic legs (rest pain, gangrene, ischemic ulcer, and ankle-brachial pressure index less than 0.40) were treated with revascularization regardless of operative risk or anticipated operative difficulty. Primary amputation was performed only when no graftable distal vessels were present (14 primary amputations [2.8%]) or in neurologically impaired, hopelessly nonambulatory patients. The mortality for revascularization was 2.3%, and the median hospital stay was 11 days. During follow-up, 41 limbs (7%) required amputation, 31 after failure of revascularization and 10 despite patent revascularizations. Renal failure had an adverse influence on limb salvage (67%) because of a significantly increased requirement for amputation despite patent revascularizations. We conclude aggressive limb revascularization in patients with critical lower-extremity ischemia results in low operative morbidity and mortality and excellent long-term limb salvage. Patients with critical leg ischemia and renal failure are at higher risk for limb loss than patients without renal failure.

Adult↗
PubMed1991

Symptoms of Raynaud's syndrome in patients with fibromyalgia. A study utilizing the Nielsen test, digital photoplethysmography, and measurements of platelet alpha 2-adrenergic receptors.

Twenty-nine female patients with fibromyalgia were questioned about symptoms of cold intolerance and Raynaud's syndrome; objective documentation of cold-induced vasospasm was obtained by a Nielsen test. Twelve patients (41%) had abnormal Nielsen test results, and 11 patients (38%) had elevated levels of platelet alpha 2-adrenergic receptors. There was a positive correlation between the percentage of change in finger systolic pressure on cooling (Nielsen test) and the number of alpha 2-adrenergic receptors. There was poor correlation between Raynaud's syndrome symptoms and an abnormal Nielsen test result. Digital photoplethysmography showed a normal waveform in 2 of 3 patients. We hypothesize that a subgroup of patients with fibromyalgia syndrome have an up-regulation of alpha 2-adrenergic receptors as a cause of their exaggerated reaction to cold.

Adult↗