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Biomedical subjects

M L Friedell

Publications and source records attributed to M L Friedell.

16 recordsLinked to original sources
PubMed2001

Surgery for carotid artery stenosis following neck irradiation.

Carotid angioplasty and stenting (CAS) is being promoted for patients with carotid artery stenosis who have received neck irradiation. We reviewed our experience with carotid endarterectomy (CEA) following neck irradiation to determine if indeed postoperative and long-term problems were an issue in these patients. Over the past 13 years, 10 patients with a history of neck irradiation underwent 11 procedures. The average time interval between radiation treatment and surgery was 14 years (range 1-44). All carotid arteries were repaired with a standard endarterectomy, eight of which were patched. Three patients had undergone a radical neck dissection on the side ipsilateral to the carotid lesion. They received a pectoral myocutaneous flap (PMF) to protect the carotid artery and optimize wound healing. The lack of perioperative complications and of morbidity indicate that carotid reconstruction for patients with previous neck irradiation is safe and durable. Until long-term favorable results with CAS are available for these patients, operative intervention should remain the standard treatment.

Aged↗
PubMed2000

Is there a role for interval appendectomy in the management of acute appendicitis?

Interval appendectomy (IA) remains a controversial subject in surgery. To determine its effectiveness we reviewed our results with this approach. From January 1990 through December 1998 a total of 73 patients underwent appendectomy, five (7%) of which were interval in nature. These IA patients had a palpable abdominal mass or delayed presentation that led to CT scan. The decision to delay surgery was determined by two factors: 1) a CT scan that showed advanced inflammatory changes (phlegmon or abscess) associated with acute appendicitis and 2) a rapid response to conservative management. All patients received antibiotics-first intravenous and then oral. Repeat CT scans were performed before surgery and showed a virtual resolution of the inflammatory process. Appendectomy was delayed from 35 to 66 days from the time of diagnosis (average 51 days). There were no preoperative complications, the operations were uneventful, and there were no significant postoperative sequelae. IA appears to convert an unfavorable surgical situation potentially fraught with complications (fistula, abscess, wound infection) to one that is essentially elective in nature. It should be considered for the patient who is found to have an extensive periappendiceal inflammatory process, is clinically stable, and responds favorably to initial nonoperative management.

Acute Disease↗
PubMed1998

Peripherally inserted central catheters revisited.

BACKGROUND: This study compares central venous catheters (CVC) and peripherally inserted central catheters (PICC) for indications for insertion, complications, and economic impact. METHODS: A retrospective review of 838 (283 CVC, 555 PICC) consecutively placed venous catheters reflected 49,365 CVC and 11,814 PICC days. RESULTS: There were 57 (20%) complications in the CVC group, 197 (35%) complications in the PICC group. PICC were associated with a statistically significant increase in the incidence of catheter malfunction (P = 0.0005), arm vein phlebitis (P = 0.0004), and overall complications (P = 0.00001). A higher complication rate was noted in PICC inserted for chemotherapy (P = 0.00001) and parenteral hyperalimentation administration (P = 0.04). Charges for inpatient insertion of PICC and CVC were $500 and $2,500, respectively. CONCLUSIONS: PICC have a significantly higher complication rate than CVC. PICC provide cost-effective central access of 2 to 3 weeks' duration, reserving operatively placed CVC for longer access requirements.

Adult↗
PubMed1996

Is hyperbaric oxygen a useful adjunct in the management of problem lower extremity wounds?

Hyperbaric oxygen (HBO) is currently being used in the treatment of nonhealing or "problem" wounds of the lower extremities. In an attempt to evaluate the efficacy of HBO in problem wounds, a retrospective study of the HBO experience at Orlando Regional Medical Center was conducted. From 1989 to 1994, fifty-four patients with nonhealing lower extremity wounds resulting from underlying peripheral vascular disease and/or diabetes mellitus were treated with HBO. Wounds were grouped into the following five categories: (1) diabetic ulcers (n = 17 [31%]); (2) arterial insufficiency (n = 8 [15%]); (3) gangrenous lesions (n = 6 [11%]); (4) nonhealing amputation stumps (n = 13 [24%]); and (5) nonhealing operative wounds (n = 10 [19%]). Each patient received an average of 30 treatments. Outcomes for all 54 patients treated with HBO in this study were dismal. None of the patients experienced complete healing, six (11%) showed some improvement, 43 (80%) showed no improvement, and in five cases (9%) results were inconclusive because these patients underwent concomitant revascularization or amputation. Thirty-eight of the 43 patients who showed no improvement (88%) ultimately required at least one surgical procedure to treat their wounds. Thirty-four patients (63%) developed complications, most commonly barotrauma to the ears, which occurred in 23 patients (43%). The average cost of 30 HBO treatments was $14,000 excluding daily inpatient charges. Based on the experience with HBO therapy at Orlando Regional Medical Center and the paucity of good supporting literature, it is difficult to justify such an expensive, ineffective complication-prone treatment modality for problem extremity wounds.

Amputation Stumps↗
PubMed1992

High ligation of the greater saphenous vein for treatment of lower extremity varicosities: the fate of the vein and therapeutic results.

This study was carried out to determine the subsequent fate of the greater saphenous vein and the efficacy of its high ligation along with surgical excision or sclerotherapy of varicosities. From 1988 to 1990, 22 patients underwent high ligation and sclerotherapy, 22 underwent high ligation and varicose vein excision, and four underwent high ligation alone. There were 36 women and 12 men patients. The average patient age was 48. Sixty limbs were scanned by duplex ultrasound pre- and postoperatively to determine the status of the greater saphenous vein. Average follow-up time was 10 months. Patients and surgeons rated the results of therapy for ablation of varicosities and alleviation of symptoms. Surgical complications were evaluated. At postoperative scan, 47 greater saphenous veins (78%) were found to be completely patent, nine (15%) were thrombosed for a short segment (less than 10 cm) and four (7%) were more significantly thrombosed. Those limbs in which high ligation and sclerotherapy were performed had the highest complete patency rate (96%). Patient and surgeon satisfaction was good to excellent in every case. The only complications were three symptomatic greater saphenous vein thromboses. Although follow-up is relatively brief, complete patency of the ligated greater saphenous vein was found in most cases. High ligation allows preservation of a patent greater saphenous vein, which can be used as an arterial conduit at a later date and gives therapeutic results comparable to stripping without the additional morbidity.

Combined Modality Therapy↗
PubMed1991

A comparative review of in situ versus reversed vein grafts in the 1980s.

In patients requiring an infrainguinal bypass who have an ipsilateral intact GSV, the choice between the reversed and in situ vein graft should be determined by the operative findings and the site of the distal anastomosis. When the ipsilateral GSV has either been removed or is of poor quality, ectopic autologous vein should be used in most circumstances and certainly for bypass to the infrapopliteal arteries. In reviewing the results of the two types of vein bypass to the popliteal artery, the results of two prospective, randomized studies and recent retrospective, nonrandomized reports suggest that there is no difference in patency rates between the two techniques. When performing a bypass to this level, the surgeon should not routinely use one method, but tailor the operative management to the individual patient. However, when the two bypass procedures to the infrapopliteal arteries were compared, the results of a prospective, randomized study and recent retrospective, nonrandomized reports furnish strong evidence that ISVGs provide better long term patency rates than RVGs. These results favoring use of distal ISVGs in nonrandomized reports are even more impressive, since the in situ technique was often preferentially chosen over the reversed vein method when only small diameter GSVs were available and when the bypass was performed to the distal tibial or pedal arteries. Many vascular surgeons agree with the conclusion that the ISVG is the bypass of choice for infrapopliteal bypass when an intact GSV is available. Although both the in situ and reversed vein techniques provide excellent long term patency rates for infrainguinal bypasses, and the vascular surgeon should be able to adapt this technique and approach for the individual patient, further randomized, prospective studies with extensive follow-up evaluation and a large number of patients are necessary to definitively resolve which technique provides optimal patency rates for arterial reconstruction of the lower extremity.

Anastomosis, Surgical↗
PubMed1988

Origin of deep vein thrombi in an ambulatory population.

Eighty symptomatic ambulatory outpatients with acute deep vein thrombosis were evaluated with ascending contrast venography and ultrasonic imaging to determine the origin and distribution of thrombosis and to analyze clinical risk factors. Isolated calf vein thrombosis was present in 42.5 percent of the limbs, combined calf and proximal deep vein thrombosis in 47.5 percent, and isolated proximal thrombosis in 10 percent of the limbs. Discontinuity of thrombus was present in 55 percent, whereas 45 percent exhibited a continuous column of thrombus. The results of this study indicate that in the ambulatory outpatient population, acute deep vein thrombosis begins segmentally in the calf and proximal vessels and frequently coalesces into a continuous column of thrombus over several days. We believe that all cases of acute deep vein thrombosis should be treated and patients with evidence of previous acute deep vein thrombosis should be closely monitored for possible recurrences.

Adult↗
PubMed1988

The use of split-thickness skin as an autogenous arterial conduit.

Eight mongrel dogs were anesthetized using general anesthesia, and graft consisting of split-thickness skin obtained from their abdomen was devised and inserted in each of their infrarenal aortas. Six of the grafts were reinforced with meshed polytetrafluoroethylene (PTFE) as an outer layer to prevent potential aneurysmal dilatation of the skin graft. None of the dogs received aspirin at any time. The dogs were sacrificed at one, four, and six weeks. The grafts were examined with light microscopy and three of them were analyzed with scanning electron microscope. All grafts remained patent and none formed aneurysmal dilatations. None of the dogs developed infections or aortoenteric fistulas. Of the three grafts that showed thrombus-free areas, all were oriented with the epidermis facing the lumen. The three grafts where the epidermis formed the external surface did not degenerate in any area. Endothelium-like cells continuous with the host vessel were present on all grafts at 4 and 6 weeks by light or scanning electron microscopy. Preliminary data from this study indicated that split-thickness skin may be a suitable arterial conduit. Even if it does not prove to have long-term patency rates, it may be a suitable temporary conduit until infections resolve and synthetic prostheses can be reinserted.

Animals↗
PubMed1988

Progress in the diagnosis of deep venous thrombosis: the efficacy of real-time B-mode ultrasonic imaging.

Seventy-six limbs with clinically suspected acute deep venous thrombosis (DVT) were evaluated by means of ultrasonic imaging (UI) to define the ability of this technique to detect acute and chronic venous obstruction and to determine the origin and distribution of venous thrombi. UI was compared with ascending contrast phlebography in 46 limbs and was found to be 100% accurate in detecting both acute and chronic venous thrombosis. Overall, acute DVT was present in 63 of 76 limbs (83%) studied. Acute DVT was found in 24% and recurrent acute DVT in 76%. Our results indicate that although the calf veins are the most common site of involvement (89%), thrombi may frequently arise simultaneously in multiple anatomic sites. All limbs with recurrent acute DVT had evidence of previous calf thrombi but only 13% had previous proximal disease. This suggests that asymptomatic calf DVT is common and the prevalence of recurrent acute DVT is significantly greater than previously believed. We found UI is a practical, accurate, non-invasive method for investigating the pathogenesis of venous disease.

Acute Disease↗
PubMed1987

Use of ultrasonic venography in the evaluation of venous valve function.

Forty healthy limbs and 31 limbs with suspected deep venous insufficiency were imaged with real-time B-mode ultrasound to determine valve location, anatomic characteristics, and function. Valve function was evaluated by comparison with Doppler ultrasonographic techniques, and the data clearly indicated that ultrasonic venography accurately localized and determined the extent of deep venous reflux. Ascending contrast venography was performed in 15 postphlebitic limbs for assessment of valve location. The results indicate that ultrasonic venography is a more accurate method for visualization of valves in this group of patients. Therefore, ultrasonographic imaging is a valuable technique for evaluating limbs with chronic venous insufficiency.

Humans↗
PubMed1987

Femorofemoral grafts for lower limb ischemia caused by intra-aortic balloon pump.

From January 1975 to December 1985, 1454 patients had an intra-aortic balloon inserted for cardiac assistance. Eighty balloon-dependent patients had severe limb ischemia and required a femorofemoral graft (FFG) (5% of the total group of patients). Twenty-nine of the 80 patients with grafts (or 36%) left the hospital and 28 were followed up for an average of 40 months to determine late complications associated with the crossover grafts. All grafts remained patent. The 28 patients were classified into five groups according to the degree and type of lower limb ischemia. Group I consisted of 13 asymptomatic patients (46%); group II had four (14%) patients with mild claudication caused by preexisting peripheral arteriosclerosis; group III comprised four patients (14%) without preexisting disease but claudication subsequent to the FFG; group IV had five patients with irreversible ischemic sequelae before grafting ending in amputation, foot drop, or persistent paresthesia; and group V consisted of two patients with graft infection (7%). The perioperative mortality rate of the balloon-dependent patients with an FFG (64%) reflects the gravity of the cardiac condition. Placement of an FFG to relieve limb ischemia in these patients is followed by few immediate or late complications in the survivors and any persistent limb changes were related to the prolonged ischemia present before revascularization. Our data suggest that in balloon-dependent patients with limb-threatening ischemia, aggressive use of the FFG is limb-saving, durable, and allows continuation of balloon support.

Adult↗
PubMed1987

B-mode ultrasonic imaging in the preoperative evaluation of saphenous vein.

This prospective study was undertaken to determine if B-mode ultrasonic imaging of the greater saphenous vein can provide reliable information about anatomy, sites of valves, and location of major tributaries or duplicate systems. Preoperative ultrasonic imaging was performed on 15 consecutive patients prior to in situ saphenous bypass. The findings of the ultrasonic evaluations were compared with the intraoperative findings. Preoperative assessment of the greater saphenous vein was performed with a high resolution real-time B-mode ultrasonic imager. The procedure was performed with the patient seated with the leg extended. The saphenous vein was imaged starting at the ankle. A waterproof pen was used to mark the vein. The locations of valves and tributary vessels were marked and the diameter of the saphenous vein was recorded. These results were compared with operative findings. In all 15 patients, the saphenous vein was imaged. There was 100 per cent accuracy in the detection and location of valve sites. In one patient, the proximal portion of the vein was thrombosed and this was detected by the B-mode scan. There was exact correlation in 14 of 15 limbs (93%). The one error was due to the examiners' failure to identify a triple venous system; only a double venous system was identified by scan in this patient. The actual venous diameter was consistently within 0.5 mm of that measured by the ultrasound imager. In all patients, the ultrasound image demonstrated the correct anatomic location and size of the vein. In conclusion, B-mode ultrasonic imaging provides an accurate description of the anatomy of the saphenous vein, without the morbidity associated with contrast venography.

Aged↗
PubMed1985

Cecal necrosis in the dialysis-dependent patient.

Necrosis of the cecum occurs in various settings, including low-flow states. Cecal necrosis in two dialysis patients with documented, sustained hypotension is presented. Spontaneous left colon perforations, which have been previously reported in renal failure patients, were considered secondary to distention from constipation. The cecum may be more susceptible to ischemia than the remainder of the colon. Maximal distention develops at this point. With an associated low-flow state, in a possible watershed area, necrosis can occur. The diagnosis of cecal necrosis and perforation should be entertained in any dialysis patient with an acute abdomen. Early exploration may be necessary.

Cecal Diseases↗