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Biomedical subjects

J V Robbs

Publications and source records attributed to J V Robbs.

At least 55 records · Page 3Linked to original sources
PubMed1995

Surgical management of penetrating mediastinal arterial trauma.

Fifty-two patients with penetrating injury to the arteries caudal to the thoracic inlet and cephalad to the heart came under the care of the Durban Metropolitan Vascular Service, South Africa, over a 13-year period. The innominate artery was the commonest vessel injured (n = 23). Five patients (11%) had multiple vessel injuries, four of which involved the aortic arch, and 18 (34%) had arteriovenous fistulae. Mortality was greatest with injuries involving the aortic arch (n = 17) and ascending aorta (n = 4) in which intra-operative exsanguination was the leading cause of death (five patients). Injuries involving the inferior and posterior walls of the aortic arch and those located between the innominate and left common carotid origins were the most difficult to control. Seven patients with aortic injuries presented with cardiac tamponade, three of whom had associated injuries involving the atria. Seven of 21 (33%) patients with aortic injuries died compared to 2 of 31 (6%) with aortic arch branch injury (p < 0.05, chi-square) for an overall mortality of 17%.

Adolescent↗
PubMed1995

Arterial complications of the thoracic outlet syndrome.

OBJECTIVES: Arterial complications due to compression of the thoracic outlet are uncommon. The objective of this study was to review our fairly extensive experience with this problem with particular reference to its management. METHODS: Patients entered into the Vascular Clinic database were reviewed over an 11 year period. Twenty six records were found. In 24 patients the vasculopathy was caused by a cervical rib (complete in 15) and in two by an anomaly of the first rib. In all patients the basic arteriopathy was a fibrous structure with a post-stenotic aneurysm in 13. Seventeen presented with a fixed pulse deficit; 13 had a palpable aneurysm and 12 had distal embolisation. RESULTS: Two patients refused operation. In 22 with cervical rib, the rib was removed via a supraclavicular incision, an anterior scalenectomy was performed and the arterial pathology repaired on its merit, usually by vein graft replacement or bypass. In two with first rib anomalies these were resected by the transaxillary route. Twenty three patients have been followed for between 3 months and 10 years; 20 are cured and three have residual claudication. CONCLUSIONS: Our results show that simple excision of the cervical rib via the supraclavicular route together with vascular reconstruction is adequate. This is in disagreement with the view of those who advocate routine excision of the first rib in addition to cervical rib excision.

Adult↗
PubMed1995

A wolf in wolf's clothing--the abdominal compartment syndrome.

Four patients are described in whom massive abdominal distension after laparotomy led to increased airway and central venous pressure and severely reduced urine output. All cases were associated with massive fluid resuscitation and operative findings were a grossly oedematous bowel with free fluid under pressure in the abdomen. These findings are consistent with the diagnosis of intra-abdominal compartment syndrome. In 1 case trauma was remote from the abdomen indicating that abdominal surgery or trauma may not be a prerequisite for the development of the condition. Recognition of the features of the condition is essential as it can only be treated by decompression of the abdominal contents.

Abdomen↗
PubMed1994

Traumatic arteriovenous fistula: experience with 202 patients.

Experience with the management of 202 patients with 210 traumatic arteriovenous fistulas is reported. Penetrating trauma accounted for 98 per cent of injuries caused mainly by stabs (63 per cent) and missile wounds (26 per cent). Seven of 15 patients with shotgun wounds had multiple lesions. Over half of all fistulas occurred in the cervico-mediastinal vessels; abdominal and thoracic vessels were infrequently involved. The upper limbs were involved in 22 per cent and the lower limbs in 20 per cent. Some 133 patients were diagnosed and treated within 1 week of injury; 69 presented 1 week to 12 years later. Machinery murmur was noted in 61 per cent of the early presenters, but was an almost universal finding in those presenting late. Only three patients had cardiac failure and all had underlying cardiomyopathy. Active overt haemorrhage was not common. Arterial continuity was restored in 80 per cent of cases, usually by autogenous reconstruction. Venous injury was usually treated by ligation or lateral suture. Patients treated within 1 week of injury had a lower rate of perioperative mortality and morbidity than those treated late, due mainly to technical difficulties in controlling the vessels caused by fibrosis and massive venous dilatation. If a policy of selective exploration of penetrating trauma is to be followed, careful assessment for arteriovenous fistula must be made and the patient evaluated at regular intervals for several months. Shotgun injuries require routine angiography at the time of presentation. The earlier treatment is instituted, the better the results.

Abdominal Injuries↗
PubMed1994

Arterial reconstruction for non-specific arteritis (Takayasu's disease): medium to long term results.

There is little information on reconstructive arterial surgery for Takayasu Arteritis, and the approach is generally negative in this regard. Common causes of death are stroke, aneurysm rupture and the complications of renovascular hypertension and renal failure. The present study aims to examine the results of arterial reconstruction in the medium and long term in patients with histologically proven Takayasu's disease. In the last 11 years 134 patients have been referred to the vascular service of whom 81 (60%) were suitable for operation. Forty-nine were women; age range 3-45 years (average 29.5 years). In 28 the disease was confined to the aortic arch (Type 1); 41 had descending aortic involvement (Type II); six had a combination of arch and aortic disease (Type 111) and two associated cardiac lesions (Type IV). Four had isolated peripheral lesions (Type V). Seventy percent of these lesions were aneurysmal. Of the 28 type I patients, two had aortic arch reconstruction, seven segmental replacement. Of the 49 with type II, III and IV disease 26 had thoraco-abdominal aortic replacement using a bypass technique. The remainder had infrarenal aortic replacement and bypass procedures. Type V (four patients) had interposition grafts. Overall operative mortality in the Type I patients was 3.6% (stroke) and in the type II-IV 4%. All of the latter followed operation for aneurysm rupture and there were no elective deaths. Three months to 11 years after operation four patients (5%) developed fatal progression of the disease and seven (8.9) non-fatal disease progression of whom three required surgical intervention.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Aortofemoral bypass in the presence of total juxtarenal aortic occlusion.

Forty-two patients with total juxtarenal aortic occlusion were offered aortobifemoral bypass over a 6 year period. The majority presented with claudication and males predominated. In all patients, aortobifemoral bypass was successfully performed. The groins were initially explored and the aorta was then thrombectomised prior to the standard aortobifemoral bypass. Follow-up period ranged between 6 months and 5 years. There was a 4.8% perioperative mortality. Graft occlusion occurred in two patients in the immediate postoperative period, resulting in major amputation in one patient. Three patients developed graft occlusion during the period of follow-up, none of whom required amputation. Graft sepsis occurred in one patient and one patient developed a false aneurysm. We conclude that angiography cannot predict the feasibility of bypass in the presence of total aortic occlusion, and in our hands aortobifemoral bypass is feasible in all these patients. Early results are no different from the rest of the patients with aortoiliac disease.

Adult↗
PubMed1993

Carotid endarterectomy in Durban--the first 10 years.

This study was a prospective evaluation of the Durban experience with carotid endarterectomy over the past decade. Since 1981, 478 carotid endarterectomies have been performed in 411 patients. The majority of these patients were white men, with an average age of 60.6 years. The indication for surgery was a lateralising transient ischaemic attack or amaurosis fugax in 65.5%, lateralising stroke (< 1 year before surgery) in 14.4%, non-lateralising global cerebral ischaemia in 9.4% and asymptomatic carotid stenosis in 10.7%. Carotid endarterectomy was performed under general anaesthesia and with invasive monitoring; 25% of patients underwent selective shunting. After open carotid bifurcation endarterectomy, all but 6 underwent primary closure (99.4%). The combined major stroke/mortality rate was 6%. This audit identified a group of patients who presented with a history of stroke within the year preceding surgery and who had a significantly higher postoperative stroke/mortality rate of 20.2%. Long-term follow-up, ranging from 1 month to 96 months, showed 80.7% to be stroke-free after 8 years. This audit demonstrates a postoperative stroke/mortality rate comparable to that of other series and additionally confirmed the durability of carotid endarterectomy in the long term.

Adult↗
PubMed1993

The potential benefit of pre-operative assessment of amputation wound healing potential in peripheral vascular disease.

Choosing the most distal amputation level that will heal is difficult in patients with peripheral vascular disease. From 1984 to 1988, 965 patients underwent 1,563 amputations for lower limb peripheral vascular disease at King Edward VIII Hospital, Durban. The primary amputation revision rate was 51% with a mortality rate of 23.1%. Random pre-operative assessment of amputation wound healing potential using a transcutaneous oxygen pressure index was investigated over the 4-year period, 1987-1990. This was responsible for a reduction in the amputation revision rate to 8.2% in patients tested.

Amputation, Surgical↗
PubMed1991

Aortobifemoral bypass for the critically ischaemic limb--is it worth while?

Little is written of the place of aortobifemoral bypass as a limb or below-knee-level amputation stump salvage procedure in patients presenting with critical ischaemia with threat of limb loss. Over a 4-year period 151 patients referred to the Vascular Service of the University of Natal Hospitals with aorto-iliac occlusive disease and a threatened limb were studied. All were submitted to aortobifemoral bypass. Patients were divided into two subgroups: group 1 patients presented with rest pain or focal necrosis and were submitted to aortobifemoral bypass with concomitant digital or transmetatarsal amputation; and group 2 patients were submitted to a guillotine-type below-knee amputation in view of ascending infection or extended necrosis that made below-knee amputation impracticable. The objective was to obtain healing of the stump at the below-knee level. Early results within 1 month of operation were as follows: 5 patients (3.3%) died of myocardial infarction. There was no graft sepsis, and groin wound sepsis occurred in 7 (4.5%). Of the group 1 patients 8 required major amputation (8.2%). Three patients in group 2 required proximal above-knee revision (14.3%). The overall limb or stump salvage rate within 1 month of surgery was 89.4%. It was possible to follow up 105 patients in group 1 and 18 in group 2 for between 2 years and 5 years. In group 1, 2.9% required major proximal amputation and 3.8% a subsequent femoral-to-distal bypass. In group 2 none required subsequent major proximal amputation. Overall in those available for long-term follow-up 97% retained the use of a salvaged limb or stump.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1991

Surgical management of mycotic aneurysms.

Mycotic aneurysms not associated with trauma or atherosclerosis are uncommon. Their clinical presentation is insidious and lacks definite diagnostic criteria. This retrospective study of 14 patients treated over a period of 9 years confirms this, and shows that half are associated with a predisposing infected focus and that the main presenting clinical feature is that of a painful mass (64%) which is often mistaken for some other diagnosis. The main extracranial, extrathoracic site of predilection was the iliofemoral segment (65%). The main diagnostic investigation was angiography, which was also used to uncover silent aneurysms elsewhere in the arterial tree. Urgent surgical treatment is mandatory since complications may occur at any time and these may include life-threatening bleeding. Two of our patients experienced life-threatening gastro-intestinal bleeding while in hospital. The mainstay of treatment was surgical resection and reconstruction using an autologous vein or artery if possible. The more serious complication of graft failure was encountered mainly in patients who underwent prosthetic graft repair. It is in this group that 2 of the 3 early postoperative deaths occurred, from graft thrombosis and mesenteric infarction. Overall, surgical repair was attended with good outcome (77%).

Adolescent↗
PubMed1991

Paediatric arterial injury: management options at the time of injury.

Arterial injury in children presents a challenge, even to the experienced vascular surgeon. In order to evaluate established management guidelines, the clinical records of all patients under 12 years of age presenting with arterial injury were studied. Over a 4-year period, a total of 40 patients were treated; 29 after blunt trauma, and 11 with penetrating injuries. Upper limb vessels were involved in 17 cases, lower limb in 20, renal in two and facial in one. In most patients with penetrating injury, haemorrhage from the wound made urgent surgery mandatory. In the 29 patients who had sustained blunt injury and were submitted to operation, no repair was necessary in 14. The clinical signs of absent pulses were due to spasm. Thirteen required reverse vein graft, and in two no repair was attempted: in one patient the renal artery was ligated, and in the other ischaemic forearm muscles precluded any recovery. In those children referred for vascular opinion, it would appear that arterial spasm is an important problem after blunt trauma. In this subgroup, operation may be averted in some patients with the use of intravenous digital subtraction angiography. Exploration is mandatory if there is any doubt about the limb viability.

Angiography, Digital Subtraction↗
PubMed1990

Non-traumatic cervicomediastinal vascular lesions. A clinicopathological study in the different populations of Natal.

Apart from those suffering from vascular trauma, 334 patients with cervicomediastinal lesions have been treated at Durban Metropolitan Hospitals over a period of 8 years. Sixty-seven of these were black (20%), 79 Indian (24%), 10 coloured (3%) and 178 white (53%). Atherosclerotic disease was found in 50% of black, 80% of Indian and 99% of white patients; the remaining patients suffered from miscellaneous conditions, such as arteritis, fibromuscular dysplasia, mucoid degeneration and radiation. Aneurysmal disease was found in 33% of blacks, but only 2% of Indians and 0.6% of whites; the remainder had occlusive lesions. More blacks presented with complete stroke (16%) than in the other population groups, who presented most frequently with episodic neurological dysfunction. It is concluded that atherosclerosis is as common as arteritis in blacks, while it is the most common precipitating factor for cervicomediastinal lesions in the other two groups. Aneurysms and complete stroke are also common in blacks.

Adult↗
PubMed1990

Gangrenous fingers: the tip of the iceberg.

Over a 7-year period 535 patients presented to our Vascular Service with gangrenous digits, of which 35 had a gangrenous finger (6.5%). The aetiology of digital vessel occlusion was embolic in 15 and thrombotic in 20 patients. The patients came from all ethnic groups with a mean age of 45 years. Proximal atherosclerotic disease of the subclavian artery was the predominant source of embolism (60%), although a variety of other lesions were also responsible. In the thrombotic group, ten were due to collagen vascular disorders, eight to thromboangiitis obliterans and two followed thrombogenic rheological disorders. Twenty-nine patients underwent local amputation and six required chemical debridement. In addition reconstructive surgery, usually extrathoracic bypass, was performed in 13 patients and cervical sympathectomy in nine patients. The operative mortality was zero and none required major amputation on follow-up. It was concluded that the gangrenous finger, unlike the gangrenous toe which is often due to atherosclerosis, may reveal a wide variety of disorders demanding aggressive diagnostic evaluation and therapy.

Adult↗
PubMed1990

Do pre-operative antibiotics reach the operative field in amputation surgery for peripheral vascular disease? A pilot study.

Amputation surgery in patients with peripheral vascular disease is associated with high revision and mortality rates. A prospective pilot study examined the intra-operative delivery of cefoxitin sodium to the amputation site, and used pre-operative transcutaneous oxygen pressure measurement to try to predict the tissue antibiotic levels at the amputation site. Antibiotic concentrations were measured in plasma and muscle from the amputation site at the time of amputation, and a significant difference in antibiotic distribution was found between healed and failed amputations. Transcutaneous oxygen pressures correlated with the antibiotic distribution.

Adult↗
PubMed1989

Measurement of cefoxitin levels in tissue using high-pressure liquid chromatography.

A high-pressure liquid chromatography (HPLC) method that successfully measured cefoxitin (a modification of the antibiotic cephamycin C) levels in subcutaneous tissue, muscle, and aortic and peripheral arterial walls has been developed. Samples were obtained from 11 patients submitted to prosthetic aortic replacement. All patients received an intravenous bolus dose of cefoxitin 2 g just before induction of anaesthesia. Blood and tissue samples were taken at various intervals intra-operatively. The tissue samples were mechanically homogenised. Both plasma and the tissue homogenates were deproteinated with trichloracetic acid. The cefoxitin was separated by HPLC and measured by ultraviolet absorbance. The results show that the tissue concentration of the drug fell over a 4-hour period and that all levels exceeded the MIC90 (minimum inhibitory concentration that inhibits growth of bacteria at the 90% level) for most aerobic and anaerobic pathogens for at least 3 hours.

Abdominal Muscles↗
PubMed1989

Surgical options in traumatic injury to the extrahepatic biliary tract.

A series of 53 patients who sustained extrahepatic biliary tract trauma were analysed to define the role of the various surgical options. Of the 45 patients with gallbladder injuries, 39 were due to stab wounds. Nine of the 45 injuries were repaired by primary suture without complication. Five patients underwent cholecystostomy and all developed biliary fistulae, which resulted in prolonged hospitalization. Cholecystectomy was performed in 31 patients; in retrospect many of these gallbladders could have been preserved because on only eight occasions was the gallbladder extensively damaged. Of eight extrahepatic bile duct injuries, the three partial transections managed by primary repair had a successful outcome, while the five complete transections were managed by a variety of techniques. Delayed diagnosis, failure of operative recognition of the injury and improper management were factors that led to mortality in two patients and prolonged morbidity in another. We conclude that suture repair is the operation of choice for gallbladder stab wounds without extensive injury. Ductal injury must be recognized. Partial transections are best managed by primary repair. Complete transections should be managed by primary duct jejunal anastomosis if the expertise is available.

Adolescent↗
PubMed1989

The selective management of penetrating wounds of the back.

Fifty patients with penetrating wounds of the back were prospectively evaluated and managed selectively on the basis of physical examination. Despite the theoretic problems of evaluating the retroperitoneum, physical examination was found to be a reliable method of determining the need for laparotomy. Every patient who had a significant injury had evidence for this on initial physical examination and no patient judged to have a normal examination required laparotomy. The negative laparotomy rate was 4% and no patients died as a result of delayed surgical intervention. Careful physical examination and surgical judgment allow for safe management of penetrating back wounds.

Adolescent↗