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Biomedical subjects

J V Sitzmann

Publications and source records attributed to J V Sitzmann.

At least 109 records · Page 6Linked to original sources
PubMed1989

The internal retention repair of massive ventral hernia.

We report the results of a new method of primary repair of massive ventral hernia in 409 patients using internal retention sutures. Notably, 40 per cent of these patients had failed Marlex mesh repairs. The mean transverse diameter of their hernial defects was 10.4 +/- 0.7 cm (range, 4-18 cm). The overall recurrence rate was 2.5 per cent, superior to other methods of primary repair, and equal or superior to Marlex mesh repair. Wound infection occurred in 5 per cent. The risk of wound infection was significantly increased (P less than 0.05) in patients with a history of prior wound infection. We conclude that the internal retention method of primary repair of ventral hernia for defects less than 18 cm in diameter is equal to Marlex in the repair of previously infected recurrent hernias of this size.

Adult↗
PubMed1988

Mesoatrial shunt hemodynamics.

Hemodynamic profiles were obtained for patients with portal hypertension secondary to the Budd-Chiari syndrome who underwent mesoatrial shunting procedures. In contrast to the well-known hyperdynamic, low-resistance state of chronic cirrhosis, patients with the Budd-Chiari syndrome had normal cardiac index and systemic vascular resistance values before anesthesia and surgery. Opening the mesoatrial shunt produced a 46% (p less than 0.01) increase in cardiac index and a 38% (p less than 0.01) decrease in overall systemic vascular resistance. Right atrial pressure and pulmonary capillary wedge pressures were sharply increased--by 5.3 mm Hg and 4.7 mm Hg, respectively (p less than 0.01). A mathematical model was developed to assess the cause of the observed changes in systemic vascular resistance. The model suggests that the hemodynamic changes seen with shunt opening are unlikely to be the result of shunt effects alone and that dilatation of peripheral vascular beds is probable. Thus shunting converts the normal systemic vascular resistance and cardiac index of patients with the Budd-Chiari syndrome to the high-output, low-resistance state seen in patients with chronic cirrhosis. Although the physiology is complex, we conclude that the data are consistent with release, by the shunting process, of a systemic vasodilator.

Adult↗
PubMed1987

Improved hospital morbidity, mortality, and survival after the Whipple procedure.

Between 1969 and 1986, 88 patients had a Whipple resection for adenocarcinoma of the pancreas (N = 50), ampulla (N = 19), distal bile duct (N = 10), and duodenum (N = 9). Forty-nine patients were men, 39 were women, and the mean age was 58 years (range: 34-84 years). The patients were divided into two groups on the basis of two different time periods: those operated on from 1969 to 1980 (N = 41) and those operated on from 1981 to 1986 (N = 47). There were no significant differences between the two groups in terms of mean age, sex distribution, duration of symptoms before presentation, or mean weight loss. Likewise, preoperative laboratory data were similar for both groups of patients. In addition, mean tumor size for patients with pancreatic cancer (3.5 cm vs. 3.2 cm) and patients with nonpancreatic periampullary cancer (1.9 cm vs. 2.2 cm) was similar in both groups, as was the incidence of positive lymph nodes. Among the 41 patients operated on during the first period, hospital morbidity and mortality rates were 59% and 24%, respectively. In contrast, hospital morbidity and mortality rates were 36% and 2%, respectively, among the 47 patients operated on during the recent period. During the recent period, more Whipple procedures were performed each year (7.8 vs. 3.4) and by fewer surgeons (3.4 operations/surgeon vs. 1.9 operations/surgeon). In addition, between 1981 and 1986, there were fewer total pancreatectomies (9% vs. 39%), fewer vagotomies (26% vs. 76%), and more pyloric-preserving procedures (30% vs. 0) performed compared with the earlier period. During the recent period, mean operative time (7.8 vs. 9.0 hours), mean estimated blood loss (1694 vs. 3271 mL), and mean intraoperative blood replacement (3.6 vs. 6.3 units) were all significantly less than in the earlier period. These findings suggest that the recent decline in operative morbidity and mortality may be due to fewer surgeons performing more Whipple resections in less time and with less blood loss. The actuarial 5-year survival rate for the 38 patients with nonpancreatic periampullary cancer was 34%. Surprisingly, the actuarial 5-year survival rate among the 50 patients with pancreatic cancer was 18%. Moreover, in the absence of positive lymph node involvement, the 5-year actuarial survival rate among patients with pancreatic cancer was 48%. No explanation is obvious for the improvement in survival among patients with pancreatic cancer.

Adenocarcinoma↗
PubMed1987

Conversion by new treatment modalities of nonresectable to resectable hepatocellular cancer.

Eleven patients with hepatocellular cancer had nonresectable lesions, ten as determined by laparotomy and one by computed tomographic (CT) evidence of inferior vena caval invasion. These patients were treated with a variety of new modalities, particularly radiolabeled antiferritin antibodies. Following treatment, seven of the 11 patients were considered to have converted their lesions to possible resectability. Six patients had complete resections, and one patient was partially resected. All patients had the common features of either nodular massive or nodular multifocal hepatocellular cancer. Relative to the patient's initial status, the quality of life remains high, and a new approach in the treatment of the nodular form of nonresectable hepatoma has been demonstrated. The present rate of such conversion to resectability is unknown. However, with further advances in radiolabeled antibody therapy, these results offer a new opportunity in the management of hepatocellular cancer.

Antibodies, Monoclonal↗
PubMed1987

A new alternative to diverting double barreled ileostomy.

A new diverting ileostomy is described which avoids the attendant problems associated with the previously described "loop ileostomy," and other described-ileostomies used in conjunction with ileoanal pull-through procedures. The ileostomy result is a functionally superior stoma, similar to that of the standard Brooke ileostomy, and requires only a local exploration for takedown. Initial experience with the procedure has been uniformly excellent and would support wider use of the "close loop" double barreled ileostomy.

Anal Canal↗
PubMed1985

Septic and technical complications of central venous catheterization. A prospective study of 200 consecutive patients.

The results of central venous catheterization for total parenteral nutrition were prospectively evaluated in 200 consecutive patients. All catheters were fabricated of polyurethane tubing inserted by the Seldinger technique. Two hundred sixty-three lines were inserted in 200 patients for a total of 4103 days. Major complications occurred in 2.3% patients. Twenty-four per cent of catheters were associated with suspected sepsis; of these, 52% were removed directly and 48% were changed over a guidewire. The total catheter sepsis rate was 5.7%. The incidence of sepsis correlated with the number of attempts to insert the line and with positive skin cultures. These data indicate that: use of the Seldinger technique to insert nonthrombogenic flexible catheters results in lower technical morbidity; the incidence of established infection is much lower than the incidence of suspected sepsis; guidewire change may be performed without risk to the patient or interruption of therapy; sepsis rates can be decreased by reducing the number of attempts to catheterize the subclavian vein; and sepsis rates correlate with positive skin cultures at the insertion site.

Adult↗
PubMed1984

Splenic complications of a pancreatic pseudocyst.

Six patients with pancreatic pseudocyst involving the spleen have been presented. The complications reported included massive hemorrhage into the pseudocyst, sepsis with splenic infarction, and splenic vein thrombosis. The diagnosis of intrasplenic pseudocyst based on clinical findings alone is difficult to arrive at but should be suggested by the presence of a mass in the left upper quadrant. Sonography and computerized axial tomography may be particularly helpful in confirming splenic involvement. Selective celiac arteriography should be performed whenever splenic involvement is suggested in order to confirm the diagnosis and to search for pseudoaneurysm formation. Urgent surgical intervention is usually warranted in view of the high incidence of serious complications and the propensity toward rapid clinical deterioration. Resection of the pseudocyst by splenectomy and distal pancreatectomy is the treatment of choice.

Adult↗
PubMed1984

Management of arm arterial injuries.

Management, morbidity, and mortality of arterial injuries of the arm are dependent upon site of injury, promptness and accuracy of diagnosis, and involvement of contiguous structures. To determine results and establish principles of management, a retrospective analysis was undertaken of 109 arm arterial injuries from the thoracic inlet to the wrist in 102 patients. Iatrogenic injuries were excluded. Arterial injuries were classified into those affecting the upper arm (subclavian, axillary, and brachial) and those affecting the lower arm (radial, ulnar, and interosseous). This proved to be a useful classification because of differences in management and results at these two levels. Thirty-six or one third of injuries involved the upper arm (13 subclavian, seven axillary, and 16 brachial) and 73 involved the lower arm (30 radial, 29 ulnar, 12 radioulnar, and two interosseous). Of the 19 individuals in hypovolemic shock when first examined, 12 (63%) had sustained upper arm injuries. Fifty-four percent of all patients had nerve involvement when initially examined, the majority (76%) sustaining lower arm injuries. Vein grafts were required during 19 repairs whereas resection and end-to-end repair were successful on 62 occasions. No synthetic grafts were used. Ligation alone was performed 18 times, only among those with lower arm injuries. Two patients died, both of hypoxic brain damage. Twenty-eight percent of patients suffered late disability despite an adequate vascular repair. Overall, 7% of patients with upper arm injuries and 21% of those with lower arm injuries were disabled when last seen. Upper arm arterial injuries are more of a threat to life than are lower arm injuries, but lower arm arterial injuries are more disabling, mainly because of associated nerve involvement.

Adolescent↗
PubMed1984

Dimethylsulfoxide-treated, cryopreserved venous allografts in the arterial and venous systems.

Autologous saphenous vein is the preferred conduit for most vascular reconstructive procedures; however, many authorities have emphasized the need for a reliable alternate. This study was designed to assess the short-term patency of dimethylsulfoxide-treated, cryopreserved saphenous vein allografts in both high- and low-flow states. An early patency rate of 58.3% was found for such allografts interposed in the arterial system. No instance of aneurysm formation was noted. Allografts interposed in the venous system uniformly occluded within 5 weeks. However, in animals treated with aspirin and dipyridamole there was an 83% early patency rate for cryopreserved allografts in the venous system. These studies suggest that dimethylsulfoxide cryopreservation is a viable technique for venous allograft preservation as demonstrated by satisfactory short-term patency of grafts implanted in the arterial system. The results also suggest that treatment with aspirin and dipyridamole has a beneficial effect on the early patency of such grafts placed in the venous system.

Animals↗
PubMed1983

Percutaneous transhepatic management of complex biliary problems.

A series of 27 patients with complex biliary problems secondary to previous biliary operations is presented. The patients are divided into two groups: (1) patients with acute perioperative biliary problems; all had biliary leak with abscess, biliary cutaneous fistula, and/or stricture following cholecystectomy or common duct exploration and (2) patients with chronic postoperative biliary problems; all had previous repair of biliary stricture or injuries with late stricture formation. Early management of all patients included placement of a percutaneous biliary stent. Abscesses were drained operatively, and biliary leaks or fistulas were allowed to close spontaneously. Jaundice and cholangitis were allowed to resolve. Following stabilization, management of stricture, if present, was addressed. Eight acute patients had strictures, of which four were partial and three were dilated percutaneously. Four were complete and required operative repair. All 12 chronic patients had strictures, of which six were partial and successfully managed with percutaneous dilatation. Four patients also had common duct stones which were successfully crushed percutaneously. The authors conclude that percutaneous transhepatic drainage offers significant advantages in the early stabilization and treatment of patients with complex biliary problems, and that partial strictures of the biliary tree may be managed successfully by percutaneous dilatation.

Adolescent↗
PubMed1983

The use of sclerotherapy for treatment of postmastectomy wound seromas.

Five patients who developed seromas following mastectomy with lymph node dissection were treated with aspiration of the seromas and instillation of a sclerosant solution containing tetracycline. All seromas resolved promptly without infection, flap necrosis, or recurrence. The technique is recommended for treatment of this postoperative complication.

Adenocarcinoma↗
PubMedDate not supplied

Conversion of unresectable to resectable liver cancer: an approach and follow-up study.

In the last decade, significant improvement has been achieved in the treatment of hepatocellular cancer by combining therapies from different disciplines, and using effective biologic response modifiers to improve response to existing therapy. While operative resection remains the only curative modality, a select group of patients with unresectable fibrolamellar or nodular variant, can be converted from unresectable status to resectable by combining chemotherapy and radiotherapy. We reviewed the recent experience with intra-arterial chemotherapies and use of external beam radiotherapy and isotopic immunoglobulin-directed radiotherapy in the treatment of unresectable hepatocellular cancer. While significant tumor response can be achieved with these therapies they are short-lived, and long-term survival is poor. When combined with operative resection, however, a significant survival advantage is achieved. The expected survival of the unresectable patient is then altered from 18 to 24 months for chemotherapy or radiation alone, or when used in combination, to 44 months for patients converted to resectable status. We conclude that the need for more effective chemotherapy is imperative, and the major role for chemotherapy or radiotherapy in hepatocellular cancer is to convert an unresectable patient to resectable status.

Carcinoma, Hepatocellular↗
PubMedDate not supplied

Hepatocellular carcinoma: findings on spiral CT during arterial portography.

BACKGROUND: To determine characteristic imaging features of hepatocellular carcinoma (HCC) on spiral CT during arterial portography (SCTAP) and to correlate the presence or absence of spontaneous portosystemic shunts with the degree of hepatic parenchymal enhancement during SCTAP in patients with HCC. METHODS: SCTAP scans of 20 patients with HCC were retrospectively analyzed for tumor features, degree of hepatic parenchymal enhancement, and presence or absence of spontaneous portosystemic shunts. RESULTS: Nineteen tumors (95%) were hypoattenuating masses and one (5%) was isoattenuating compared with the liver on SCTAP. In seven patients (35%), the tumor was homogeneous in attenuation. Tumor margins were smooth and regular in 12 patients (60%). Vascular invasion and encapsulation were depicted in 10 patients (50%). A high degree of hepatic parenchymal enhancement was observed in 14 patients; one of them (7%) had spontaneous portosystemic shunts. Poor or moderate enhancement was observed in six patients; five of them (83%) had spontaneous portosystemic shunts (p < .001). CONCLUSION: The presence of a low attenuated homogeneous intrahepatic mass with associated vascular invasion on SCTAP scans should raise the possibility of HCC. The presence of spontaneous portosystemic shunts is associated with poor or moderate parenchymal enhancement.

Adult↗
PubMedDate not supplied

Multifocal angiomyolipoma in a patient with tuberous sclerosis.

Angiomyolipomas are rare lesions that occur most commonly in the kidney, but also can occur in the liver and rarely, in the lymph nodes. Its rare association with tuberous sclerosis has been suggested, but never proved. We report a patient with multiple visceral angiomyolipomas as well as visceral vessel aneurysms and tuberous sclerosis. The association of the three lesions suggests a possible common connective-tissue defect.

Adult↗
PubMedDate not supplied

Acute isovolemic hemodilution during major hepatic resection--an initial report: does it safely reduce the blood transfusion requirement?

Surgical resection remains the mainstay of treatment for patients with hepatic tumors, despite the associated morbidity including the need for blood transfusion. Acute isovolemic hemodilution (AIH) has been shown to decrease the transfusion requirement for cardiac, urologic, and orthopedic procedures. However, the reported experience with AIH during hepatic resections is limited. Seven patients underwent major hepatic resection from July 1992 to June 1994 with standard AIH. Their clinical parameters were compared with those of nine matched control patients during the same time period. AIH and control patients had similar preoperative laboratory values (hematocrit, bilirubin, and coagulation studies), extent of liver resection, and pathologic diagnoses. Mean tumor diameters were larger in the AIH group (9.3 cm vs. 5.8 cm). Most important, patients managed with AIH required homologous blood transfusions significantly less often than the control group (14% vs. 67%; P=0.05). Furthermore, if they did receive transfusions, AIH patients needed fewer units of red cells (0.1+/-0.1 units vs. 1.7+/-0.6 units). There was no morbidity associated with AIH. AIH can be safely performed in patients undergoing major hepatic resection for malignancy. AIH appears to reduce the number of patients requiring homologous blood transfusion as well as the number of units transfused per patient. This technique warrants further study in a larger prospective, randomized trial.

Blood Loss, Surgical↗
PubMedDate not supplied

Should hepatic resections be performed at high-volume referral centers?

Recent studies have demonstrated the relationship between clinical outcomes of complex surgical procedures and provider volume. Hepatic resection is one such high-risk surgical procedure. The aim of this analysis was to determine whether mortality and cost of performing hepatic resection are related to surgical volume while also examining outcomes by extent of resection and diagnosis, variables seen with this procedure. Maryland discharge data were used to study surgical volume, length of stay, charges, and mortality for 606 liver resections performed at all acute-care hospitals between January 1990 and June 1996. One high-volume provider accounted for 43.6% of discharges, averaging 40.6 cases per year. In comparison, the remainder of resections were performed at 35 other hospitals, averaging 1.5 cases per year. Data were stratified into these high- and low-volume groups, and adjusted outcomes were compared. The mortality rate for all procedures in the low-volume group was 7.9% compared to 1.5% for the high-volume provider (P <0.01, relative risk = 5.2). No overall differences were observed between low- and high-volume providers in total hospital charges. When analyzing by procedure type and diagnosis, lower mortality was seen in the high-volume center for both minor and major resections, as well as resections for metastatic disease. It was concluded that hepatic resection can be performed more safely and at comparable cost at high-volume referral centers.

Black People↗