Biomedical subjects
Publications and source records attributed to R B Rubenstein.
A new technique of percutaneous occlusion of the aorta is described herein. The catheter is inserted through the femoral artery and has a central lumen for placement over a safety guide, if needed. The method is applicable in instances of exsanguinating hemorrhage, such as ruptured abdominal aortic aneurysm.
Bilateral radical neck dissection with internal jugular vein extirpation, be it simultaneous or staged, results in severe cephalic venous hypertension. Symptoms remit with time, however, acutely contribute to the morbidity of the procedure. Internal jugular vein replacement using autogenous saphenous vein that is fashioned into a spiral conduit has been used in three patients undergoing bilateral or second side radical neck dissection. The technique entails construction of a large vein conduit by wrapping saphenous vein around a chest tube in a spiral fashion. Patients treated had objective relief of the acute venous hypertension based on cephalic venous pressure measurements. The three patients undergoing the spiral vein grafting were notable for the lack of any expected symptoms derived from venous hypertension, and postoperative venograms demonstrate graft patency at one to two weeks.
The use of the fiberoptic bronchoscope for pinpointing a lesion during the course of surgical endobronchial extraction is described. Two cases are outlined: removal of a retained foreign body; and excision of a pedunculated bronchial tumor. The use of a bronchoscope as an aid during thoracotomy for bronchial lesions is emphasized.
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Insertion of the intra-aortic balloon through the subclavian artery is described. This antegrade method of insertion is useful in patients in whom the retrograde transfemoral approach is not possible.
A method to anastomose saphenous vein grafts to a calcified or severely arteriosclerotic ascending aorta is presented. A portion of the aorta is replaced by a synthetic prosthesis from which the grafts are delivered through individual openings.
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Excluded loop syndrome may develop in patients who undergo jejuno-ileal bypass surgery with the excluded small intestine drained via an ileosigmoidostomy. A unique case of a morbidly obese male who underwent the procedure while on methadone maintenance therapy is presented. The major factor in the development of this disorder appears to be the high intraluminal pressures within the sigmoid colon which prevent adequate egress from the excluded loop. Narcotic medications tend to induce or intensify the syndrome.
Cerebral spinal fluid (CSF) levels of methadone were measured in nine methadone maintenance patients requiring lumbar punctures for medical or surgical treatment. Concurrent serum methadone levels were also determined. The CSF concentration of methadone in all cases was a fraction of the corresponding serum level--ranging from 2 to 73%. The CSF concentrations of methadone ranged from 0.010 to 0.097 ng%. Peak methadone levels in CSF appeared approximately 3 - 8 hours after methadone administration.
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One hundred patients on methadone maintenance admitted to our surgical service were analyzed. The average duration of prior narcotics abuse was ten years and was followed by an average of 2.2 years of methadone maintenance treatment. Sixty-three patients were admitted on an emergency basis, half of these for trauma. Sixty-two patients underwent operative procedures. There were four deaths, none directly related to methadone use. Five patients were admitted for intestinal obstruction secondary to methadone ingestion. This disease entity results from fecal impaction which is induced by methadone's spastic effect on the gastrointestinal tract. Evidence of chronic liver disease was present in half the patients. The associated medical illnesses presented no problems with anesthesia. WHILE METHADONE MAINTENANCE WAS CONTINUED IN THE ACCUSTOMED DOSAGE, POSTOPERATIVE ANALGESIA WAS ACCOMPLISHED SATISFACTORILY WITH 5O TO 100 MG DOSES OF MEPERIDINE AT 3 HOUR INTERVALS, AS REQUIRED.
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Seven patients with Hickman/Broviac catheters implanted via the percutaneous subclavian route are reported to have had catheter separation and embolization; one catheter implanted via cephalic vein cutdown also separated. The method of percutaneous subclavian catheter insertion is briefly described, and the mechanism of catheter separation is discussed. Percutaneous insertion routes the silicone catheter between the clavicle and first rib, producing compressive/shearing force which can cause the catheter to break--usually after several months. Embolized catheter fragments can be retrieved with a percutaneous transfemoral venous snare. The described complication represents a 1% incidence. Recommendations to minimize this problem include: placement of subclavian puncture at or lateral to midclavicular line; chest x-rays at 2- to 3-month intervals to identify catheter indentation at the thoracic inlet; early removal of catheters for patients with radiologic evidence of significant catheter compression.