Biomedical subjects

R de Geest

Publications and source records attributed to R de Geest.

12 recordsLinked to original sources

PubMed1991

Risk control and prevention of spinal cord damage due to surgery of thoracoabdominal aneurysms: medicolegal aspects.

Surgery of thoracoabdominal aneurysms is accompanied by many complications of which spinal cord damage is the most serious. Such a complication tends to be the subject of litigation and medicolegal assessment. This report presents a risk control concept focussed on the reduction of spinal cord damage after surgery for a thoracoabdominal aneurysm. This concept may provide a basis for a risk management program in major surgery. Apart from sparing the patient a serious complication, improvement of the quality of care and anticipation of a medicolegal assessment were considered valuable benefits of such an effort. It is described how the threat of litigation--also in Europe--may affect clinical practice. A definition of surgical failure is described related to the five elements of risk homeostasis: complexity, linkage, cascade, human factor and safety margins. Limitations of risk control in the surgery of thoracoabdominal aneurysms are described. Finally the role of perception of risks by patient and doctor as well as the importance of informed consent and adequate disclosure are described in respect of medical quality improvement and litigation.

Aorta, Abdominal↗

PubMed1990

Experimental and clinical use of somatosensory evoked potentials in surgery of aneurysms of the descending thoracic aorta.

The use of somatosensory evoked potentials (SEP) for the detection of spinal cord ischemia in surgery of the descending thoracic aorta was studied in nine dogs. Also 18 patients (group A) operated upon without distal aortic perfusion and 10 patients (group B) operated upon with distal aortic perfusion were studied. Tibial nerve stimulated SEP was used. Crude SEP characteristics and the reliability of SEP were assessed. In dogs the preservation of SEP corresponded with absence of neurological damage (p less than 0.02). Loss of SEP and late or absent recovery were associated with presence of neurological damage histopathologically proved (p less than 0.05). In group A SEP recording was affected by peripheral ischemia whereas this phenomenon was absent in group B during perfusion. In group A no relation was observed between the preservation, loss, and recovery of signal and the presence of neurological damage. In group B loss and recovery of SEP corresponded with assumed reperfusion of the spinal cord. Additional SEP recording obtained from stimulation of the skin overlying the fourth lumbar vertebra and of the medullary conus were preserved over a longer period. In patients this type of SEP was especially useful and reliable in case distal aortic perfusion was not used.

Aged↗

PubMed1989

Assessment of risk factors for spinal cord ischaemia in surgery of thoracoabdominal aneurysms without use of adjuncts.

Between January 1983 and June 1986, 61 patients underwent resection of a thoracoabdominal aneurysm (TAA) by means of simple cross-clamping without the use of adjuncts. All patients survived the operation. Mortality was 6.5% at 30 days and 16.4% at 1 year. Spinal cord injury occurred in 8 patients. Three patients sustained paraplegia and 5 patients recovered from paraparesis within 6 months. In univariate analysis, risk factors were the presence of symptoms (P less than or equal to 0.01) and emergency operation (P less than or equal to 0.03). Spinal cross-clamptime (ACX), aetiology and the number of open intercostal arteries (ICA) did not appear to be single denominators for spinal cord injury. Testing clusters of variable related to spinal cord injury revealed an increased risk for the group of patients (n = 20) with type I (most of the thoracic and the upper abdominal aorta) and type III (the distal half of the thoracic and varying segments of the abdominal aorta) aneurysms, when the number of ICA was greater than or equal to 4 or less than or equal to 1, with a spinal ACX of greater than or equal to 35 min, and in the presence of symptoms and previous dissection (P = 0.001). In patients (n = 19) with type II aneurysm (involving most of the thoracic and most of the abdominal aorta) an increased risk was present when the number of open ICA was greater than or equal to 4, with a spinal ACX of greater than or equal to 35 min and in the presence of symptoms (P = 0.01). Spinal cord injury was confined to these types of TAA (P less than or equal to 0.001) and paraplegia occurred only in type I and III aneurysms.

Adult↗

PubMed1988

Simultaneous extensive extracranial and coronary revascularization. Long-term follow-up up to 13 years.

Simultaneous surgery for extensive extracranial and coronary revascularization was performed in 168 patients (mean age 61 years), from 1974 up to June 1987; 116 patients (69%) were in NYHA class III or IV, 133 (79%) had triple vessel disease and 51 (30%) had left main stem lesions. One or more previous myocardial infarctions were present in 96 patients (57%); normal preoperative left ventricular function was present in only 35%. In 22 cases, additional cardiac procedures were performed. Symptomatic extracranial disease was present in 76 patients (45%), arch vessel surgery was performed in 29 (17%) and bilateral haemodynamically significant carotid disease was present in 58 (35%). Operative mortality (3%) was mainly cardiac and operative morbidity mainly neurological (7%). Actuarial survival at 5 years (75%) and 10 years (57%) was mainly determined by the cardiac survival (87% at 5 years and 70% at 10 years), while neurological follow-up deaths were rare (neurological survival 97% at 5 years and 91% at 10 years). Late morbidity was more cardiac than neurologically determined; actuarial curves showed 72% to be free of all serious events or death at 5 years, and 47% at 10 years.

Adult↗

PubMed1987