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Biomedical subjects

N M Rich

Publications and source records attributed to N M Rich.

At least 37 records · Page 2Linked to original sources
PubMed1996

A quick and simple method to close vascular, biliary, and urinary tract incisions using the new Vascular Closure Staples: a preliminary report.

Traditional suture reconstruction of tubular organs creates a perforating needle injury, leaves suture material on the endothelial or mucosal surfaces, and is cumbersome when done endoscopically. One alternative method of reconstruction of tubular organs could use the new nonpenetrating clip to create an everted closure. In five pigs, a longitudinal incision of the infrarenal aorta, inferior vena cava, left ureter, gallbladder, and the common bile duct (in two) was closed with Vascular Closure Staples (VCS-clips). Four weeks after surgery, all ten blood vessels remained patent with no thrombosis. There was a well-healed wound with continuous intimal layer. The ureteral, gallbladder, and common bile duct wounds healed without leakage or obstruction in all animals. There was complete mucosal bridging of the wound, although in some specimens one or two clips were exposed to the lumen. The VCS-clips are easily and quickly applied and are safe insofar as can be determined by short-term follow-up.

Animals↗
PubMed1996

An external audit of laparoscopic cholecystectomy in the steady state performed in medical treatment facilities of the Department of Defense.

OBJECTIVE: This study provides the first objective assessment of a complete patient population undergoing laparoscopic cholecystectomy in the steady state. The authors determined the frequency of complications, particularly bile duct, bowel, vascular injuries, and deaths. SUMMARY BACKGROUND DATA: This retrospective study, conducted for the Department of Defense healthcare system by the Civilian External Peer Review Program, is the second complete audit of laparoscopic cholecystectomy. Data were collected on 9130 patients undergoing laparoscopic cholecystectomy between January 1993 and May 1994. METHODS: The study sample consisted of clinical data abstracted from the complete records of 9054 (99.2%) of the 9130 laparoscopic cholecystectomies performed at 94 military medical treatment facilities. RESULTS: Of 10,458 cholecystectomies performed in the Military Health Services System, 9130 (87.3%) were laparoscopic and 1328 (12.7%) were traditional open procedures. Seventy-six medical records were incomplete: however, there was sufficient data to determine mortality and bile duct injury rates. Of the remaining 9054 cases, 6.09% experienced complications, including bile duct (0.41%), bowel (0.32%), and vascular injuries (0.10 percent). The mortality rate was 0.13%. Access via Veress technique was used in 57.6% and Hasson technique in 42.4% of patients. Intraoperative cholangiograms were performed in 42.7% of the cases with a success rate of 86.2%. Eight hundred ninety-two (9.8%) patients were converted to open cholecystectomies. CONCLUSIONS: In the steady state, despite an increase in the percentage of laparoscopic cholecystectomies performed for nonmalignant gallbladder disease, there continues to be minimal complications and low mortality.

Adolescent↗
PubMed1994

An external audit of laparoscopic cholecystectomy performed in medical treatment facilities of the department of Defense.

OBJECTIVE: This study provided an objective survey by an outside auditing group of a large, complete patient population undergoing laparoscopic cholecystectomies, determined the frequency of complications, especially bile duct injuries, and presented a system for classifying and comparing the severity of bile duct injuries. SUMMARY BACKGROUND DATA: This is the first study of laparoscopic cholecystectomy to encompass a large and complete patient population and to be based on objectively collected data rather than self-reported data. The Civilian External Peer Review Program (CEPRP) of the Department of Defense health care system conducted a retrospective study of 5642 patients who underwent laparoscopic cholecystectomies at 89 military medical treatment facilities from July 1990 through May 1992. METHODS: The study sample consisted of the complete records of 5607 (99.38%) of the 5642 laparoscopic cholecystectomy patients. RESULTS: Of the sample, 6.87% of patients experienced complications within 30 days of surgery, 0.57% sustained bile duct injuries, and 0.5% sustained bowel injuries. Among 5154 patients whose procedures were completed laparoscopically, 5.47% experienced complications. Laparoscopic procedures were converted to open cholecystectomies in 8.08% of cases. Intraoperative cholangiograms were attempted in 46.5% of cases and completed in 80.59% of those attempts. There were no intraoperative deaths; 0.04% of the patients died within 30 days of surgery. CONCLUSIONS: The frequency of complications found in this study is comparable to the frequency of complications reported in recent large civilian studies and earlier, smaller studies. The authors present a system for classifying bile duct injuries, which is designed to standardize references to such injuries and allow for accurate comparison of bile duct injuries in the future.

Adolescent↗
PubMed1991

The valvular anatomy of the iliac venous system and its clinical implications.

Clinical and phlebographic evidence exists that correlates the presence of varices of the vulva, posterior thigh, and the pelvic congestion syndrome with insufficiency of the internal iliac venous system (pelvic dumping syndrome). Information in the modern medical literature regarding the valvular anatomy of the internal iliac veins and its tributaries is limited. We dissected 82 iliac venous system specimens in 42 human cadavers (29 men, 13 women) to gain information on the relationship between the disease described and the anatomy of the region. Each specimen contained common, external, and internal iliac veins, including the tributaries of the latter. We recorded the anatomic variations of the internal iliac vein trunk and the location of valves in the complete iliac venous system, including 485 tributaries of the internal iliac veins. Five specimens of internal iliac vein had calcified thrombosis or were extensively involved with pelvic carcinoma and were not suitable for valve study, which left 79 specimens for analysis. The internal iliac vein drained into the external iliac venous system by means of a single trunk in 73% of the specimens and by two well-formed and separated trunks in 27% of the specimens. In one specimen (1.2%) the internal iliac vein drained directly into the inferior vena cava (parallel internal and external iliac veins). One specimen had a well-developed valve in the common iliac vein (1.2%). The external iliac vein had one valve in 26.2% of the specimens. This vein had three times as many valves on the right side as in the left (39.6% vs 14.6%: p = 0.0106).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1990

Alterations in serum creatine kinase and lactate dehydrogenase. Association with abdominal aortic surgery, myocardial infarction and bowel necrosis.

Experimental studies have shown that peripheral serum creatine kinase and lactate dehydrogenase change with bowel infarction. Some clinical reports have suggested that similar changes occur in patients. This prospective study documents the changes in these enzymes associated with acute myocardial infarction, acute bowel necrosis (MES INF), and uncomplicated abdominal aortic reconstruction. Analysis of 15 patients with AMI, 13 patients undergoing major AAS, and eight patients with MES INF has shown that these conditions may be differentiated by analysis of serum CK and LD isoenzymes. The study suggests that in the absence of electrocardiographic changes, a patient with epigastric distress with elevated levels of serum CK and either CK-MB or CK-BB bands present may well have a mesenteric rather than a myocardial infarction. Acute myocardial infarction can be ruled out further through analysis of serum LD1/LD2 ratios.

Aged↗
PubMed1990

Intermittent claudication caused by atherosclerosis in patients aged forty years and younger.

Intermittent claudication may represent a severe limitation in daily life-style for young, active patients and may result in loss of professional career for members of the armed forces. Our recent experience with young patients with atherosclerotic claudication was reviewed to determine whether more liberal use of angioplasty and surgery is warranted in these patients to salvage their military careers and improve their life-styles. A systemic review was made of patients aged 40 years and younger with atherosclerosis who have undergone arteriography at our institution during the past 67 months. From this study, 22 patients were found with the initial complaint of intermittent claudication. Fifteen of these patients (68%) had occlusive disease confined to the iliac arteries, and six (27%) had single-level occlusive disease in a femoropopliteal distribution. Only one patient had multilevel disease. Symptoms of coronary occlusive disease developed in five patients (23%) within 38 months of the onset of claudication, and two of these patients died of myocardial infarctions. Of 19 patients who underwent interventions to correct symptoms of claudication, 16 (85%) had complete relief of symptoms at the end of follow-up, ranging from 6 months to 7 years. Ten of these patients remained symptom free after a single intervention, but six patients had rapid progression of disease and required secondary procedures. These results indicate that a majority of young patients with claudication caused by atherosclerosis can be returned to full active-duty status in the military after angioplasty or surgery. However, some patients may require secondary procedures to relieve recurrent symptoms caused by rapid progression of disease. We believe that an aggressive interventional approach is warranted in the evaluation and treatment of young patients with work-limiting claudication caused by atherosclerosis. These patients are at significant risk of developing premature coronary occlusive disease and should be monitored closely.

Adult↗
PubMed1989

Abnormalities of lymphatic drainage in lower extremities: a lymphoscintigraphic study.

Chronic lower-leg edema in patients with venous disorders was studied by means of lymphoscintigraphy. Lymphatic patterns of flow were evaluated prospectively in 26 patients with technetium 99m antimony trisulfide colloid injected subcutaneously in the interdigital web spaces on the feet. Most patients in this study had postphlebitic syndrome, and all of these patients had abnormal lymphoscintigraphic flow patterns. Nine had evidence of lymphatic obstruction, and one had an enhanced flow pattern. Three patients had veins used for distal arterial bypass, and all these veins showed decreased lymphatic flow. Two patients with Klippel-Trenaunay syndrome (congenital varicose veins associated with limb elongation, a capillary nevus, and an abnormal deep venous system) had obstruction to lymphatic flow, and two others had normal and enhanced patterns. Normal studies were seen in four of five patients who had veins used for coronary artery bypass grafting. The finding of decreased lymphatic flow in patients appears to be the result of the length of time from an episode of deep venous thrombosis, the occurrence and number of episodes of cellulitis and lymphangitis, and mobilization of the vein for use in distal arterial bypass surgery. This study shows that the edema attributed previously to primary venous disorders may have a significant lymphatic component. The degree of lymphatic obstruction can be determined by lymphoscintigraphy with technetium-labeled antimony trisulfide colloid.

Adult↗
PubMed1988

Management of venous trauma.

There has been considerable interest in the management of injured extremity veins since the American experience during the Vietnam War. Fortunately, there are an increasing number of reports from civilian experience in the United States that add valuable information. Although the controversy continues, it appears that there is merit in repair of many injured lower-extremity veins, particularly the popliteal vein when it is a single return conduit, assuming that the patient's general condition will permit, in an attempt to prevent acute venous hypertension initially and chronic venous hypertension subsequently. Figure 1 identifies the recovery potential that exists even if the initial venous repair fails. In contrast to thrombosis in the arterial system, recanalization is the rule in venous thrombosis. Patent valves can exist above and below the rather localized area of thrombosis. It appears that recanalization will prevent the problems of chronic venous insufficiency. It is obvious that many patients do well for years; however, the sequelae of acute venous hypertension may be more demonstrable after 10 or 15 years. There has not been similar evidence supporting a more aggressive approach in general in upper-extremity veins. However, it should be appreciated that a return pathway must remain patent, as noted in replantation of extremities. Obviously, there are differences in military and civilian wounds, with the former usually having more extensive soft-tissue destruction and obliteration of collateral veins and lymphatic channels. Unfortunately, many civilian gunshot wounds are being seen in the United States that are similar to the military type. We must not forget the lessons of the past, and we must continue to analyze our experience in the management of injured veins under a variety of conditions.

Blood Vessel Prosthesis↗
PubMed1988

Three-dimensional computer graphic modeling of ballistic injuries.

Multiple variables affect the tissue destruction caused by missiles, and the interaction of these variables is incompletely understood. The recently developed technology of computerized solid modeling now makes it possible to analyze these parameters in three dimensions. A technique for creating solid models of organic structures is described. The tissues within the boundaries thus defined are ascribed physical attributes by means of finite element analysis with data derived from empirical studies. An interactive user-friendly program is being developed combining this modeling with a probabilistic scheme (Monte Carlo simulation) to describe a variety of wounding scenarios. The data from these predictions will be compared with information from wound registries and the model refined until it can project consistently accurate patterns of injury.

Computer Graphics↗
PubMed1988

Intra-abdominal vascular injury secondary to penetrating trauma.

There were 85 patients in this series. The overall mortality was 17.6%. Gunshot wounds were responsible for 51 injuries, with a 21% mortality. There were three stabbings and three shotgun blasts, with a mortality of 10% and 33%, respectively. There were 127 intra-abdominal vascular injuries. The majority were to the SMA and its branches: 34. The highest mortality occurred with protal vein and combined aortic and vena caval injuries (80%). Fatalities averaged twice as many vascular injuries as survivors. There were 194 organ injuries. A liver injury predicted the highest mortality as did injuries to the spleen, lung, and pancreas. The presence of shock and the ability to rapidly control the source were the major predictors of survival. Fatalities averaged a Trauma Score of 7.5; survivors averaged a score of 14.0. There were 12 deaths which occurred intra-operatively and three postoperatively, for a total of 15 deaths. Once the patients made their way from surgery, their survival was 96% assured. Early suspicion of an intra-abdominal vascular injury followed by rapid exposure and control of hemorrhage are the keys to successful management.

Abdominal Injuries↗