Roof patch repair of an aortoduodenal fistula resulting from suture line failure in an aortic prosthesis

A unique method of managing aortoduodenal fistula due to proximal suture line failure eight years after resection of an aortic aneurysm is presented. A roof patch of woven Dacron was employed in the repair rather than resection and replacement of the entire prosthesis. Immediate operation is recommended for the patient presenting with the “herald bleed” of aortointestinal fistula after prosthetic aortic replacement.     

Clostridial myonecrosis of the abdominal wall. Resection and prosthetic replacement

A case of extensive clostridial myonecrosis of the anterior abdominal wall is described in an elderly patient after anterior resection of the sigmoid colon. After extensive resection of the abdominal wall, the defect was bridged by omentum and reinforced with Marlex mesh. Mesh skin grafts were applied to the granulation tissue which formed rapidly from the underlying omentum. This prosthetic abdominal wall proved to be durable despite subsequent reoperation for recurrent carcinoma.     

Traumatic perforation of the sigmoid colon through schistosomal ulcerations

A case is presented in which the colon was perforated through a S. mansoni ulcer after blunt abdominal trauma. This is believed to be a unique situation. The colonic complications of schistosomiasis are discussed, and it is expected that they will be seen more frequently in the United States.     

Management of acute aortic occlusion.

Acute aortic occlusion is most often seen in elderly patients with advanced cardiac disease. The management of these patients has been facilitated by the use of extraanatomic bypass. Over the past 2 years, six patients aged 55 to 87 years presented to our medical center with acute aortic occlusion, three after major operative procedures. One patient had a thrombosed abdominal aortic aneurysm; in the other five patients differentiation between saddle embolus and thrombosis of the distal aorta was impossible. There was one operative death. Four of the other five patients underwent axillobifemoral bypass and one underwent aortofemoral thrombectomy. All survived, and none required amputation. Two of the three patients who underwent preoperative aortography developed transient renal failure postoperatively. Aortography is of little value in diagnosis and is probably contraindicated in acute aortic occlusion. Our recommendation for operative management includes (1) preparation of the patient for possible axillobifemoral bypass, (2) angiography of distal runoff via both femoral arteries, (3) attempt at bilateral aortofemoral embolectomy with Fogarty catheters, and (4) axillobifemoral bypass if embolectomy fails to restore normal pulsatile flow.     

Pancreatitis after cardiac surgery: A morphologic study

Acute pancreatitis is a well known occurrence after upper gastrointestinal and biliary tract surgery when local trauma plays a major role in the pathogenesis of this complication. The incidence of pancreatitis after surgical procedures during which local trauma to the pancreas does not occur is extremely low (less than 0.1 per cent). In the present study the incidence of unexplained pancreatitis in 182 patients who died after cardiac surgery was 16 per cent. The role of ischemia in the pathogenesis of pancreatitis in this setting is evaluated.     

Reoperation for amputation neuroma of the cystic duct.

Two cases of amputation neuroma of the cystic duct are reported. In both instances, significant symptoms were totally relieved by excision of the neuroma. Review of the literature reveals at least twenty similar cases with the same results. Emphasis is placed on the importance of considering this diagnosis in postcholecystectomy patients after all the usual causes of right upper quadrant symptoms have been ruled out.     

Multiple circumscribed pulmonary hematomas masquerading as metastatic carcinoma

A 23-year-old patient presented with multiple circumscribed pulmonary densities two months following a motorcycle accident. A history of mediastinal irradiation as an infant and a thyroid lobectomy for adenoma when a teenager reinforced an initial diagnostic impression of metastatic carcinoma. The clinical picture was further clouded by the obvious nonunion of a clavicular fracture, giving the impression of a metastatic deposit. Ultimately, when all other diagnostic studies had failed, an exploratory thoracotomy revealed multiple pulmonary hematomas which have since regressed.     

Palliative surgery for benign superior vena caval syndrome.

The two cases reported herein bring the total up to four in the literature, so far as we have been able to determine, but even with this insignificant number, it is believed that the feasibility of the procedure and the surprising degree of palliation and rehabilitation that has been obtained and maintained for over four and a half years strongly support the feeling that a reasonable surgical procedure is now available and can be offered with a high degree of optimism for successful palliation of benign superior vena caval syndrome.     

Measured tricuspid annuloplasty: a rapid and reproducible technique.

A technique for repairing the tricuspid valve that involves principles successfully used in operative repair of the mitral valve is described. A measured orifice produces competence but not obstruction and eliminates the trial-and-error aspects of annuloplasty. The procedure can be performed with the heart beating, though it can be transiently fibrillated so that the suture may be tied without tension.     

Perforated diverticula of the jejunum and ileum

Over a ten year period, four patients with inflammation or perforation of non-Meckelian, small intestinal diverticula were treated on the surgical services of Bellevue Hospital. This entity remains uncommon but may be increasing in incidence. The patients presented with a short history of severe abdominal pain, usually accompanied by nausea and vomiting. Each patient also gave a longer preceding history of less well defined abdominal symptoms. The pathogenesis of the small intestinal diverticula is uncertain but may be related to disturbed muscular peristalsis in the small bowel analogous to the changes implicated in esophageal and colonic diverticular disease. The diverticulum may be difficult to demonstrate at operation, and careful exploration for this possibility should be carried out at the time of operation for peritonitis of obscure origin. Segmental resection and end-to-end anastomosis is the treatment of choice.     

Reconstruction of radical parotidectomy defects.

The technique of microvascular free dermis-fat flaps is an efficient method of restoring cervicofacial contour after ablative head and neck surgery. Our success in six consecutive patients, including three who had received irradiation, establishes this as a reliable technique associated with gratifying results and minimal complications.     

Axilloaxillary bypass for symptomatic stenosis of the subclavian artery

Since the association has been made between stenosis of the subclavian artery and neurologic symptoms, controversy has existed over the preferred surgical procedure for bypass. In addition, concern has been raised regarding the long-term patency and effectiveness of this extraanatomic procedure in relieving neurologic symptoms.Twenty-seven patients underwent this operation for posterior cerebral symptoms between 1973 and 1982; 25 were followed for up to 77 months (mean 26 months). Twenty-two patients had complete relief of symptoms, although 3 of them required a subsequent carotid endarterectomy. Two other patients had partial relief, and one patient's symptoms remained unchanged. Upper extremity symptoms, present in nine patients, were relieved by the operation. All grafts remained patent during follow-up. Axilloaxillary bypass is a durable procedure for symptomatic stenosis of the subclavian artery. It is a low-risk procedure and is therefore particularly suited for older patients with associated carotid artery disease.     

Nonanastomotic aneurysms in venous homologous grafts and bovine heterografts in femoropopliteal bypasses

In the absence of a suitable autologous vein for a long distal femoropopliteal bypass, the homologous vein appears to be a good substitute. However, the patency rate after one year is less than 50 per cent and nonanastomotic aneurysms occurred in one third of our patients followed for more than one year. These two complications may be related to an immune response which may be lessened by preservation of the graft in the frozen state.Bovine heterografts function well when placed subfascially for femoropopliteal bypasses ending above the knee. Failure rate is high when the distal end of the graft extends across the knee joint. In our experience nonanastomotic aneurysms have developed in 50 per cent of patent grafts followed for more than one year, although other surgeons have reported an incidence of only 3 to 20 per cent.In the follow-up of twenty-three venous homografts and twenty bovine heterografts placed as femoropopliteal bypasses, eight nonanastomotic aneurysms appeared and required replacement. This occurrence was noted in more than 33 per cent of grafts patent beyond one year. When an adequate autologous vein is not available, the composite Dacron-vein graft is the best substitute.     

Abdominal aortic surgery and the left renal vein

The existence of variations in the anatomy of the left renal vein is an important consideration for the surgeon undertaking resection or reconstruction of the abdominal aorta. These variations are not uncommon and an awareness of them is essential in preventing troublesome operative complications.Sacrifice of the left renal vein may occasionally be necessary, and if care is taken to ligate the vein on the vena caval side of the adrenal and spermatic veins and to preserve these veins, serious damage to the kidney is unlikely although not impossible.     

Early surgical intervention in premature infants with respiratory distress and patent ductus arteriosus

Ten premature infants with severe idiopathic respiratory distress syndrome and a large patent ductus arteriosus who underwent ligation are discussed. There were no surgical deaths, but two late deaths occurred. Three similar infants who were not operated on are also presented; all of them died. An additional forty-four such patients with ductus ligation reported on recently were reviewed.Evidence is presented that strongly supports ligation of the ductus as soon as it becomes apparent in infants with severe respirator-dependent idiopathic respiratory distress syndrome.The diagnosis of patent ductus arteriosus is reliably established clinically, and the relatively high complication rate associated with cardiac catheterization in premature infants contraindicates its use.     

Hemigastrectomy and truncal vagotomy in the treatment of duodenal ulcer. With a summary of related secretory data emphasizing preoperative basal acidity and postoperative basal-insulin achlorhydria

We have found carefully performed basal acidity studies before and basal-insulin testing after operation to be very helpful.The preoperative basal acidity data provide a simple physiologic basis for classifying patients and, because of the wide range of fasting gastric acidity from patient to patient (0 to 56.6 mEq/hr), alert one to the magnitude of the secretory problem that one is attempting to correct by means of an operation. (Tables II and IV.)The postoperative basal-insulin data identify the patients who are achlorhydric and consequently protected against recurrence and those who are not and in whom a recurrence may therefore develop. (Table VIII.)The preoperative basal acidity data used in conjunction with the incidence of postoperative basalinsulin achlorhydria serve as an excellent basis for judging the results of different operations and for selecting the most effective procedure for a given patient. (Table VI.)For patients who are not achlorhydric, the postoperative basal-insulin data reveal the quantity of acid still present. This, in turn, indicates whether the patient is in the category that contains the great majority of recurrent ulcers. It also identifies the cases which have the largest amount of residual vagal activity and serves as an additional basis for judging the results of different operations. (Table IX.)These secretory data enabled us to identify hemigastrectomy with vagotomy as a procedure that would in all probability be very effective in preventing recurrent ulceration twenty years before [1,2] the clinical results [4] justified that conclusion and indicated that it would be more effective than other operations in this regard. (Tables VI and IX.)We recommend truncal vagotomy with hemigastrectomy or antrectomy (40 per cent resection) as the procedure of choice for the management of duodenal ulcer when no contraindications to its use are present.We recommend truncal vagotomy with a drainage procedure for poor risk patients undergoing emergency or elective surgery. Many patients over sixty should be managed in this manner.In good risk patients and elective situations in which resection is contraindicated because of disease in the duodenal area, we would call attention to the fact that truncal vagotomy combined with gastroenterostomy has been more effective than when combined with pyloroplasty in controlling acidity especially in the higher preoperative basal acidity zones. (Table VI.) This group of patients might benefit from some selective or modified truncal technic for vagotomy if it can be used with uniform success by qualified surgeons and if the postoperative basal-insulin secretory data indicate that the late results may be expected to be significantly improved over those of truncal vagotomy with drainage.When vagotomy cannot be performed, subtotal gastrectomy (two thirds) of the Billroth II type is indicated. When neither vagotomy nor resection can or should be performed, gastroenterostomy should be used.     

Retroperitoneal aortofemoral bypass using a reversed L-shaped prosthesis

An extraperitoneal approach for aortofemoral bypass has proven superior to the transperitoneal approach. The incision starts at the tip of the eleventh rib and extends obliquely downward to 2 inches above the femoral point, where it turns further downward over the femoral artery. This approach is especially suitable for a reversed L-shaped prosthesis which extends from the aorta directly to the left femoral artery and crosses the abdomen subcutaneously to the right groin, where an anastomosis is made with the right femoral artery. The operation is simple and rapid. Morbidity is reduced and recovery is accelerated. The same incision is used to perform aortoiliac endarterectomy. Fifteen patients with occlusive disease and twenty-one with aneurysms received reversed L-shaped prostheses through an extraperitoneal approach. The procedure was superior to that involving a transperitoneal approach to the aorta and the reversed L-shaped graft was superior to the Y graft for replacement of the iliac arteries.