Professor Emeritus, Surgery - General Surgery
Trauma, especially splenic and thoracic
The purpose of this study was to test the hypothesis that venous outflow of a Brescia fistula that is patent but unusable for one of a variety of reasons can provide adequate drainage to sustain a prosthetic arteriovenous graft based on the brachial artery, thus sparing more proximal veins for future access procedures.The operation consists of placement of a prosthetic graft between the brachial artery in the antecubital space and the cephalic vein at the wrist.Between December 1998 and November 1999, 14 patients (eight male and six female; age range, 34 to 73 years; mean age, 51 years) underwent the operation. The original fistulae had been in place for 5 to 27 months (mean, 13 months). Thirteen grafts were patent at 30 days; the one early failure (24 days) was caused by infection. As of May 31, 2001, four grafts were being used (18 (1/2), 20, 23, and 28 months after placement) and four had been withdrawn in a functional state because of death (n = 3) or transplantation (n = 1). Primary functional patency rate with life-table analysis was 71%, 57%, 41%, and 41% at 3, 6, 9, and 12 months; secondary functional patency rate was 86%, 78%, 52%, and 52% at these same intervals. Three grafts had primary functional patencies greater than 18 months.Patent but unusable Brescia fistulae can provide adequate outflow to sustain arteriovenous grafts, thus sparing more proximal veins for future access procedures. The operation can extend by months or years the time during which satisfactory vascular access can be maintained in these patients, potentially increasing survival in some cases. We hope that the availability of this salvage option will encourage vascular surgeons to attempt arteriovenous fistulae at the wrist even in patients with suboptimal venous anatomy.
View details for DOI 10.1067/mva.2002.125750
View details for Web of Science ID 000177489000023
View details for PubMedID 12170217
"Damage control" in severe abdominal trauma, abdominal compartment syndrome, necrotizing fasciitis of the abdominal wall, and necrotizing pancreatitis often preclude closure of the fascia after laparotomy. Many techniques have been reported for temporary coverage of the exposed viscera, but most have had documented problems. We report the successful use, since 1989, of a temporary sutureless coverage. The viscera are covered with omentum when possible, then with a clear plastic sheet. Sump drains are placed over this layer. The entire abdomen is then covered with two layers of iodophor-impregnated adhesive plastic drape. The last 50 patients managed with this technique are reported. The most common indication (27 patients) was for treatment of severe abdominal trauma. There were no wound infections, fasciitis, or bowel obstruction. Eighteen patients died; no deaths were related to abdominal closure. Temporary abdominal covering with adhesive plastic sheeting is a rapid, safe, and readily available method for managing the open abdomen. This technique provides a physiologic milieu for the abdominal viscera, simplifies nursing care, and promotes safe closure of the abdomen at a later time.
View details for Web of Science ID 000075622800015
View details for PubMedID 9731813
From August 1987 through February 1995 we performed 42 surgical procedures in 29 patients with occluded or stenotic radiocephalic arteriovenous fistulae. Operations were designed to preserve native veins for cannulation (Group I) or to preserve access in the same forearm, bypassing the failed fistula (Group II). For 27 procedures in 22 Group I patients, cumulative primary patency was 70%, 57%, and 47% at 6, 12, and 18 months, respectively. A subgroup of patients was identified, however, in whom excellent results could be reliably predicted. Among 19 hemodynamically stable patients with mature fistulae amendable to more proximal arteriovenous anastomoses, cumulative primary patency was 100%, 81%, and 67% at 6, 12, and 18 months, respectively. Secondary patency for 17 such patients was 100%, 89% and 89% for these same intervals. In Group II only two of ten patients required use of other access sites (9 1/2, 18 1/2 months). We believe that all occluded or stenotic radiocephalic arteriovenous fistulae should be considered for surgical salvage. Excellent results can be predicted for (1) hemodynamically stable patients with (2) mature fistulae that (3) fail near the arterial anastomosis and are (4) amendable to new more proximal arteriovenous anastomoses.
View details for Web of Science ID 000071670500028
View details for PubMedID 9461110
The management of a patient with a post-traumatic common iliac arteriovenous fistula which was repaired surgically is reported. The current use of less-invasive endoluminal techniques is reviewed.
View details for PubMedID 9293370
We report a case and discuss the special considerations necessary for safe treatment of patients with polysplenia who require esophagectomy for cancer or other conditions. Polysplenia is a form of abnormal arrangement of body organs intermediate between situs solitus and situs inversus, sometimes associated with cardiac abnormalities. Abdominal manifestations include multiple spleens, a preduodenal portal vein, an interrupted inferior vena with azygous continuation, a short pancreas, and intestinal malrotation and malformations with anomalous blood supply. Esophagectomy is complicated in such patients by possible cardiac abnormalities, risk of hemorrhage from the enlarged azygous vein (adjacent to distal esophagus), limited exposure via right thoracotomy because of the dilated azygous venous system, and possibly restricted availability of stomach and colon for esophageal replacement (constraints of mobility stemming from anomalous blood supply and malposition/malrotation).
View details for Web of Science ID A1997WQ11400010
View details for PubMedID 9077725
Isolated intestinal injuries are frequently difficult to diagnose using only physical examination and routine laboratory studies. Between 1980 and 1988, ten patients were identified who had intestinal injuries and had computed tomographic (CT) scans before operation. For none of these scans was the initial reading considered diagnostic of intestinal injury. All patients came to laparotomy from 2 hours to 3 days following injury, and no patient died because of missed intestinal injury. Retrospective review of the scans revealed two to be diagnostic of intestinal perforation with free intraperitoneal air or extravasated contrast. The remaining eight scans had findings suggestive of injury. However, six additional patients had similar suggestive findings and had no evidence of intestinal injury. One patient with missed duodenal injury had not been given gastrointestinal contrast. Computed tomographic findings of intestinal trauma may be subtle or nonspecific and require optimal technique and care in interpretation. The timely treatment of this injury continues to rely on a high index of clinical suspicion and serial examinations by an experienced surgeon.
View details for Web of Science ID A1990CL06100001
View details for PubMedID 2296055