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Biomedical subjects

J D Ansley

Publications and source records attributed to J D Ansley.

At least 19 recordsLinked to original sources
PubMed1986

Infected descending aortic fistula.

Two patients, each with an infected descending thoracic aortic fistula, are described. The first patient had a postpneumonitic empyema. Thoracostomy tube drainage resulted in obliteration of the empyema cavity. Upon slight withdrawal of the tube, 49 days after its insertion, massive pulsating bleeding occurred through the sinus tract. The bleeding was controlled with manual pressure at the entry site of the chest tube, and the patient was operated upon immediately. A descending aortic defect, 3 cm long X 1.5 cm wide, at the site of the thoracostomy tube was primarily closed. Ten months after the surgical procedure, the patient has had no difficulty referable to her aortic erosion. In the second patient, 9 months after removal of the T-10 vertebra (which had a large cell tumor) and replacement of the vertebra with Dunn's metallic device, hemoptysis and left lower lobe consolidation developed. Aortography demonstrated a lobulated false aneurysm, 4 cm wide X 6 cm long, at the site of Dunn's device. A 16-mm graft was sutured end to side to the descending aorta just distal to the left subclavian artery and to the abdominal aorta below the renal arteries. The false aneurysm was then removed, the two ends of the aorta were sutured, and the stumps were covered with omental graft. Nine months after the repair the patient has had no difficulty referable to the aortic surgery.

Adult↗
PubMed1984

Peritoneovenous shunts. Lessons learned from an eight-year experience with 70 patients.

The peritoneovenous shunt (PVS) is preferred over other treatment modalities in the treatment of the cirrhotic patient who has intractable ascites. The favorable effects on nutrition, pulmonary, and renal function, in addition to prompt control of ascites, frequently overshadow potentially life-threatening complications. We summarized our experience with the PVS in 70 patients with portal hypertension at Emory University, Atlanta, and identified the perioperative complications and operative mortalities. Late complications of sepsis and variceal hemorrhage were frequent and often were fatal. Of the multiple preoperative clinical and laboratory determinants, only the serum bilirubin level (greater than or equal to 3 mg/dL) was predictive of the operative mortality and longevity of survivors. The PVS should be reserved for patients with disabling, truly refractory ascites.

Adolescent↗
PubMed1984

Variceal hemorrhage in the veteran population. To shunt or not to shunt?

Portasystemic decompression remains the most definitive procedure in the control of portal hypertension (PHT) and bleeding gastroesophageal varices (BGEV). However, controversy prevails regarding shunt timing, type, and even propriety, especially in alcoholics. Analysis of a recent portal hypertension questionnaire submitted to 75 university-affiliated Veterans Administration Medical Centers (VAMC) reflected optimism regarding portasystemic shunts for the management of bleeding varices; disappointingly, however, on the average, only 20 to 25 per cent of variceal bleeders underwent definitive surgical management of any type. Ending in January 1980, a 14-year experience at the Atlanta VAMC with 72 portasystemic shunts was reviewed and demonstrates that shunt procedures may be extended to the veteran, predominantly alcoholic, population. Criteria for successful patient selection and operation are presented. While elective variceal decompression, preferably by the distal splenorenal shunt operation, may be performed with minimal morbidity and mortality, more efficient control of alcoholism is essential to prevent late deaths from hepatic failure.

Adult↗
PubMed1981

Hemodynamics of LeVeen shunt pulmonary edema.

In order to characterize the circulatory changes which may lead to pulmonary edema following the surgical placement of a LeVeen peritoneovenous shunt, intraoperative hemodynamic studies were performed on five consecutive patients without clinical evidence of cardiac disease undergoing shunt insertion. Within 30 minutes after opening the peritoneovenous shunt, there was a marked increase in pulmonary capillary wedge pressure, cardiac output, and stroke work index, and a sharp decline in both pulmonary and systemic vascular resistances. In three patients, pulmonary edema did not occur; in one patient, pulmonary edema occurred transiently but responded to furosemide administration. In these four patients, systemic vascular resistance continued to drop over the ensuing hours and the elevated pulmonary capillary wedge pressure also decreased appropriately with furosemide. The fifth patient developed persistent pulmonary edema. In this subject, systemic vascular resistance continued to rise and the elevated pulmonary capillary wedge pressure did not respond to intravenous furosemide. This study suggests that uncomplicated LeVeen peritoneovenous shunt insertion may result in a drop in systemic vascular resistance which lowers left ventricular afterload, and, thus, may protect most patients from pulmonary edema. In contrast, a continued rise in systemic vascular resistance and afterload may contribute to pulmonary edema refractory to diuretic therapy and should probably be treated with a parenteral afterload-reducing agent.

Ascites↗
PubMed1981

Evidence for central hypertyraminemia in hepatic encephalopathy.

In mongrel dogs, the effect of end-to-side portacaval shunt on plasma, cerebrospinal fluid (CSF) and brain tyramine, tyrosine, dopamine, norepinephrine, and epinephrine were studied. It was found that the level of tyramine in plasma, CSF, and selected brain regions increased steadily after the construction of the shunts. These elevations became more pronounced when the dogs manifested symptoms of hepatic encephalopathy. In postshunted dogs with stage II and III hepatic encephalopathy, tyramine concentration in corpus striatum (1,312 +/- 371), hypothalamus (400 +/- 67.0), and midbrain (660 +/- 78.7 ng/g) was significantly (P less than 0.05) higher than the level in dogs with stage 0 and I hepatic encephalopathy and sham-operated dogs serving as controls (corpus striatum, 831 +/- 140; hypothalamus, 167 +/- 40.0; and midbrain, 132 +/- 37.4 ng/g). This was followed by a concomitant depletion of dopamine and norepinephrine in these brain regions (postshunt: dopamine 104 +/- 20.0, 3,697 +/- 977, and 105 +/- 14.1; norepinephrine 521 +/- 71.6, 81.6 +/- 13.7, and 218 +/- 31.7 ng/g; vs. sham group: dopamine 532 +/- 83.1, 8,210 +/- 1,126, and 192 +/- 35.0; norepinephrine 1,338 +/- 425, 124 +/- 21.3, and 449 +/- 89.7 ng/g) of encephalopathic dogs with portacaval shunt. Furthermore, tyramine, tyrosine, dopamine, and norepinephrine levels in plasma and CSF increased markedly as clinical features in the dogs' behavior characteristic of hepatic encephalopathy occurred, including hypersalivation, ataxia, flapping tremor, somnolence, and coma. Cerebral hypertyraminemia and a defect in sympathetic neurotransmission may contribute to the development of hepatic encephalopathy of liver disease.

Animals↗
PubMed1981

Accelerated fibrinogen and platelet destruction after peritoneovenous shunting.

Peritoneovenous shunting with the LeVeen valve is generally recognized as an effective procedure for the treatment of intractable ascites and renal failure associated with severe liver disease. We recently observed a generalized hemorrhagic diathesis in patients receiving these valves. To investigate the mechanism of this hemorrhagic complication, we prospectively performed kinetic studies with 51Cr-labelled platelets and 125I-labelled fibrinogen in ten patients. When results of studies before and after valve insertion were compared, the following reductions were noted: fibrinogen concentration, 55%; the fibrinogen survival, 49%; the platelet count, 55% and the platelet survival, 35%. No endotoxin was detectable in ascitic fluid preoperatively, and there was no apparent relationship between ascitic fluid cell counts and changes in fibrinogen and platelet survival. Until the component or components of ascitic fluid responsible for accelerated consumption can be identified and steps are taken to modify the rates of platelet and fibrinogen consumption, it would seem prudent to select patients for surgery conservatively.

Ascites↗
PubMed1980

Revascularization for severe limb ischemia.

Patients with rest pain or tissue necrosis (generally correlated with a tibial-brachial pressure index of less than 0.25) have a high probability of limb loss unless revascularization is done. These problems are usually associated with extensive and multiple segments of anatomical occlusive disease. A review of 359 patients with such problems indicates that revascularization was done in 86%, with initial success in 92% of patients. The durability of successful limb preservation proved good, with 90% of patients having a comfortable, useful limb to time of death or for one year or longer after operation. Cumulative patency rates were 90% at five years for aortofemoral reconstructions, 70% at five years for femoropopliteal bypasses, and 49% at five years for femorotibial grafts. Cumulative limb salvage rates were 93%, 81%, and 67% at five years in the same categories, respectively.

Adult↗
PubMed1980

Dacron interposition shunts for portal hypertension. An analysis of morbidity correlates.

Analysis of 79 Dacron interposition shunts performed at Emory University from 1971 to 1977 identified a number of preoperative characteristics that correlate with short-term and long-term morbidity. Initial hospital mortality was related to the degree of elevation of the bilirubin and serum glutamic oxaloacetic transaminase (SGOT), to the presence of encephalopathy and to the urgency of the shunt procedure. Cumulative survival correlated best with the preoperative SGOT and bilirubin values, but other variables, including the Child's classification, preoperative encephalopathy, serum albumin, and the age of the patient at the time of operation, also exhibited significant associations. The hospital mortality of 13% and cumulative mortality of 48% in this series are in substantial agreement with similar reports in the literature. This experience differs widely from that described by most authors, however, in two other important respects: 1) significant hepatic encephalopathy has been observed in 45% of these hospital survivors, and 2) almost one-quarter of these patients have experienced spontaneous shunt closure. Thus, major shunt related complications have occurred in 70% of the patients to date. This incidence of undesirable consequences raises a serious question concerning the continued use of the Dacron interposition shunt for elective portal decompression.

Adult↗
PubMed1980

Impending aortoenteric hemorrhage: the effect of early recognition on improved outcome.

Aortoenteric hemorrhage is the result of enteric erosion and necrosis of aortic wall or anastomotic site. Mechanical or bacteriologic causes may occur singly or in combination. The temporal sequence is such that warning symptoms, often including back pain, fever, hemotochezia, and anemia, are present long before exsanguinating hemorrhage occurs. Vigorous diagnostic efforts, including gallium-67 citrate nuclear scan and computerized axial tomography, lead to a correct diagnosis. This allows planned semielective corrective operation before severe hemorrhage begins. The ideal operation consists of extra-anatomic revascularization, excision of the infected prosthesis, bowel repair with decompression, and sump drainage. Appropriate antimicrobial therapy should be continued until healing is complete. With aggressive diagnostic and therapeutic intervention according to this plan, marked improvement in survival and limb preservation can be anticipated in patients having this complication of aortic surgery. In this series, 15 of 18 patiets having operation recovered, though delayed limb loss occurred in two.

Adult↗
PubMed1980

Analysis of Twenty-three plasma proteins in ascites. The depletion of fibrinogen and plasminogen.

The concentrations of 23 plasma proteins were measured by radial immunodiffusion in the plasma and ascites of 17 patients with cirrhosis and four patients with intraperitoneal malignancies, to learn whether there is a selectivity in the movement of proteins from plasma into ascites, analogous to that of proteinuria. Additionally, since some of the proteins are involved in coagulation, we hoped to clarify the coagulopathy frequently seen following peritoneovenous shunting of ascites. Analysis was by groups: group 1 consisted of nine patients with cirrhosis with an ascites-total protein content less than 2.5 g/dl; group 2 consisted of eight patients with cirrhosis with ascites-total protein content greater than or equal to 2.5 g/dl; and group 3 consisted of four patients with malignant ascites. The ratio of the plasma concentration/ascites concentration ([P]/[A]) for each protein was calculated for each patient. In each group the median [P]/[A] for each protein was plotted against the natural logarithm of its molecular weight (In MW). For 21 of the 23 proteins, [P]/[A] showed a close linear relationship to In MW. Fibrogen and plasminogen showed significant (p < 0.0002) elevation above the regression line relating [P]/[A] to In MW. This indicates depletion of fibrinogen and plasminogen in ascites. The ascites in group 1 showed moderate selectivity, defined as the slope of the regression line (1.59), while groups 2 and 3 were essentialy nonselective (0.35 and 0.50). Fibrin-split products were elevated in all ascites but not in plasma, indicating either fibrinolysis or fibrinogenolysis within the ascites. A normal ratio for prothrombin suggests fibrinogenolysis may be the dominant mechanism. Thus the coagulopathy induced by LeVeen valve insertion may be in part secondary to the infusion of plasmin or a plasminogen activator into the circulation.

Afibrinogenemia↗
PubMed1979

Nasogastric hyperalimentation through a polyethylene catheter: an alternative to central venous hyperalimentation.

We performed nasogastric hyperalimentation with polyethylene catheters and appropriate feeding solutions in 12 cachectic patients who had been referred as candidates for central venous hyperalimentation. Most patients had primary gastrointestinal disease. The duration of hyperalimentation averaged 31 days. Seven patients obtained rapid weight gain (average 0.3 kg/day) with the nasogastric hyperalimentation alone. An additional two were successfully repleted with the addition of parenteral fluids via peripheral veins. In the nine repleted patients, serum albumin rose by average 19%, 24-hr urine creatinine by average 21%, and triceps skinfold by average 46%. The nature of the weight gain in the nine successful cases was analyzed by the metabolic balance study technique. Average composition of the increment in weight was: 50% protoplasm, 48% extracellular fluid, 19% adipose tissue, and less than 1% bone. We conclude that nasogastric hyperalimentation can replace central venous hyperalimentation in a substantial proportion of patients now receiving the latter type of treatment.

Adult↗
PubMed1979

Vascular access for cancer chemotherapy.

A persistent problem in caring for patients receiving long-term intravenous chemotherapy for cancer is the maintenance of access to the vascular system. At Emory University Hospital between January 1975 and December 1977, 48 cancer chemotherapy patients had upper-arm bovine arteriovenous fistulas created for vascular access. The heterografts were inserted from the distal brachial artery to the proximal brachial vein under local, regional block, or general anesthesia. Grafts were functioning satisfactorily in 81% of the subjects at the time of death or at termination of treatment. The mean duration of useful graft patency for the entire group was 4.6 months, with a range of 0 to 27 months. Thrombosis of the graft was the most frequently encountered complication; infection and bleeding occurred infrequently. Reoperation was required in 35% of grafts, of which one half were salvaged. No mortality was attributable to the operative procedures or to the presence of a chronic arteriovenous fistula.

Arteriovenous Shunt, Surgical↗
PubMed1979

Enteral hyperalimentation: an alternative to central venous hyperalimentation.

Severe protein-energy undernutrition is a frequent finding among chronically ill patients. Its causes are anorexia, hypermetabolism, and malabsorption. Adverse consequences include impaired cell-mediated immunity increased susceptibility to infection, poor wound healing, weakness, and death. Spontaneous oral intake is inadequate in patients with this disorder, and therapeutic maintenance or repletion alimentation is needed. Enteral hyperalimentation is the method of choice, if tolerated. A successful treatment program usually requires a small-bore, flexible nasoenteral tube, appropriate feeding solution, and constant flow delivery of nutrient. If only partial dietary requirements are tolerated enterally, peripheral intravenous nutrient solutions can often supply the deficit. Although not suitable for all patients, enteral hyperalimentation is more physiologic, safer, easier, and more economical than central venous hyperalimentation. It would be well tolerated by many patients who now receive nutritional repletion by the latter method.

Humans↗
PubMed1979

Hyperalimentation in alcoholic hepatitis.

Enteral hyperalimentation in four patients with severe alcoholic hepatitis and anorexia increased spontaneous food intake, increased their nitrogen balance and the patients improved clinically. Seven patients with alcoholic hepatitis, who were clinically ill and able to eat only 410-1,100 calories per day, were given a 900 mosM/l. parenteral "hyperalimentation" solution by a peripheral vein (P-900). The intravenous nutrition provided daily 51.6-77.4 gm. amino acids in addition to oral intake. All patients improved. None developed detectable encephalopathy after 16-42 days of P-900 therapy. Five additional patients had ascites and alcoholic hepatitis. The daily infusion of 2,000 ml. P-900 was not associated with hyponatremia, renal failure or encephalopathy in four of these five patients who improved and continued their diuresis. P-900 therapy was discontinued in one because of progressive hyponatremia. The observations indicate that over and above the maximum tolerable oral nutrition, intravenous nutrition can be effectively utilized by clinically ill, jaundiced patients with alcoholic hepatitis without precipitating encephalopathy or interference with standard therapy of ascites.

Hepatitis, Alcoholic↗