Biomedical subjects

R C Camishion

Publications and source records attributed to R C Camishion.

At least 19 recordsLinked to original sources

PubMed1995

Documentation of abdominal exploration during laparoscopic cholecystectomy.

UNLABELLED: To assess the documentation of intraperitoneal exploration and events during laparoscopic cholecystectomy, we reviewed 200 dictated operative reports from eight different institutions. The 200 laparoscopic cholecystectomies were performed by 40 different surgeons on 158 female patients and 42 male patients. A description of the gallbladder was included in 134 (67%) reports and not mentioned in 66 (33%) reports. Fifty-four (27%) reports did not mention any intraperitoneal findings away from the gallbladder. Another 36 (18%) of the reports contained only a general comment indicating that no abnormalities were seen in the abdomen (excluding the gallbladder). The other 110 (55%) reports mentioned at least one specific site or finding in the abdomen other than the gallbladder. The most commonly mentioned sites were the liver, bowel, and stomach. Only 42 (21%) operative notes described what happened to the gallbladder contents: 30 described spillage of bile and/or gallstones and 12 stated that no spillage occurred. CONCLUSIONS: Laparoscopic cholecystectomy operative notes have often lacked a description of gallbladder appearance, documentation of abdominal exploration, and/or documentation of complete removal of the gallbladder and its contents.

Abdomen↗

PubMed1995

Bioavailability of medication delivered via nasogastric tube is decreased in the immediate postoperative period.

BACKGROUND: A study was performed to determine bioavailability of medication delivered via nasogastric tube in patients after abdominal surgery. METHODS: Acetaminophen (20 mg/kg) was administered to each patient per os at least 48 hours prior to abdominal surgery and via nasogastric tube 3 hours postoperatively. The nasogastric tube was clamped for 30 minutes after drug administration, prior to resuming suction. Serum levels of acetaminophen were measured 0, 40, and 90 minutes after each dose. RESULTS: Acetaminophen levels were significantly lower (P < 0.001) when the drug was administered via nasogastric tube postoperatively. CONCLUSIONS: Decreased bioavailability of medications delivered via nasogastric tube may have important clinical implications and should be taken into consideration during the postoperative period.

Abdomen↗

PubMed1995

Bioavailability of medication after laparoscopic cholecystectomy.

Bioavailability of medication after laparoscopic cholecystectomy has not been studied previously. There is concern about the ability of patients to tolerate oral medication postoperatively and the optimal timing of hospital discharge. In this study, each subject received 20 mg/kg acetaminophen (po) preoperatively, with a repeat dose at 6 (group 1), 12 (group 2), or 24 h (group 3) postoperatively. Serum levels were obtained 40 and 90 min after each ingestion. Bioavailability of medication was significantly decreased (p < 0.01) 6 h (group 1) and 12 h (group 2) postoperatively. Bioavailability returned to baseline by 24 h after laparoscopic cholecystectomy (group 3). This study indicates that oral medication should be used judiciously during the first 12 h after laparoscopic surgery.

Acetaminophen↗

PubMed1995

Trocar site tumor recurrence after laparoscopic-assisted colectomy.

As a variety of procedures become technically feasible with laparoscopic techniques, it becomes increasingly important to appropriately select the patients who will benefit from the laparoscopic approach. We report the case of a patient with Dukes C2 colon cancer treated by laparoscopic-assisted sigmoid colectomy who subsequently developed an abdominal wall recurrence at a trocar site scar. The case raises some concerns about the use of the laparoscopic technique in the surgical management of colon cancer.

Abdominal Muscles↗

PubMed1995

Erythropoetin accelerates hematocrit recovery in post-surgical anemia.

UNLABELLED: We evaluated the role of recombinant human erythropoietin (RHE) for treatment of severe postsurgical anemia (Hct < 25%) in 40 Jehovah's Witness (JW) patients refusing transfusion. Twenty patients (group E) received RHE either at a loading dose of 300 U/kg iv 3 times/week for 1 week followed by 150 U/kg 3 times/week in accordance with an IRB approved protocol (N = 13), or at a dose of 100 U/kg 3 times/week for humanitarian reasons (N = 7). This group was compared to 20 similar JW patients who did not receive RHE (group C). All patients received iron restoration and nutritional support. Non-parametric analysis (Mann-Whitney) was used because of sample size. Entry hematocrit was similar for both groups: H(E)(0) = 15.8% +/- 1.1 SEM (8.5-23.4) vs HC (0) = 12.8% +/- 0.9 SEM (7.3-20.6), P = 0.09. After one week, hematocrit was significantly higher in group E (H(E)(1)) = 19.3 +/- 1.1 vs HC(1) = 12.5% +/- 0.9, P < 0.0005) as was the increase in hematocrit for group E (3.6% +/- 0.9 for E vs -0.4% +/- 0.8 for C, P < 0.005). Hematocrit change in Week 2 showed an increase for both groups (2.9 +/- 0.6 for E vs 4.9% +/- 1.2 for C, P = 0.12). CONCLUSIONS: Hct recovery shows a 1-week lag in severely anemic postsurgical patients treated without RHE. Exogenous RHE appears to accelerate hematocrit recovery in the first week. Use of RHE in the immediate postoperative period may help avoid or reduce homologous blood transfusion.

Anemia↗

PubMed1994

Preoperatively assessing and planning blood use for elective vascular surgery.

Few guidelines exist for determining transfusion needs and strategies, namely, the appropriate use of autologous versus homologous blood for elective vascular surgery. To address this deficiency, we have developed and used an algorithm based on an analysis of the procedure, maximum surgical blood ordering schedule, patient status, and patient suitability for autologous alternatives. Data were derived from consecutive major vascular procedures done at our hospital from 1991 to 1992. The algorithm helps the surgeon assess transfusion need and patient suitability for autologous predonation and aids in selecting appropriate transfusion alternatives. Using this algorithm during the past year with 120 patients, we simplified transfusion decisions, reduced homologous blood use (to only 4.2%), and reduced wasting of autologous blood to less than 5% of the units predonated. We believe that the use of this algorithm will aid the vascular surgeon in choosing appropriate alternatives to allogeneic blood transfusion, thereby reducing the patient's exposure to risk. The algorithm should also reduce wasting of autologous blood.

Adult↗

PubMed1994

Perfluorocarbons as blood substitutes: the early years. Experience with Fluosol DA-20% in the 1980s.

Clinical testing of perfluorocarbons (PFC) as blood substitutes began in the early 1980's in the form of Fluosol DA-20% (FDA), a mixture of perfluorodecalin and perfluorotripropylamine emulsified with Pluronic F68. We have treated 55 patients (Treatment (T) = 40; Control (C) = 15) with intravenous infusions of 30 cc/kg of FDA as part of either a randomized, clinical trial or a humanitarian protocol. All patients were Jehovah's Witnesses who refused blood transfusion and were severely anemic (mean hemoglobin = 4.6 g/d). FDA successfully increased dissolved or plasma oxygen content (P1O2 in ml/dl), but not overall oxygen content (T group: P1O2 baseline = 1.01 +/- .27, P1O2 12hrs = 1.58 +/- .47 [p = < .0001, t-test]; P1O2 12 hrs: T = 1.58 +/- .47, C = 1.00 +/- .31, p = < .0002, t-test). This effect persisted for only 12 hours post infusion, and had no apparent effect on survival. FDA is an ineffective blood substitute because of low concentration and short half-life. Improved emulsion design may resolve these problems, thereby producing a more effective agent. Our discussion will include a review of our data plus a summary of other reports of FDA efficacy as a blood substitute.

Anemia↗

PubMed1994

A survey of preferred approach to inguinal hernia repair: laparoscopic or inguinal incision?

The recent interest in laparoscopic surgery has raised some concerns that large numbers of surgeons were recommending this "minimally invasive" approach in procedures such as inguinal herniorrhaphy before the availability of adequate data regarding safety and benefits. To determine current experience and preference levels for laparoscopic inguinal herniorrhaphy (LH), we conducted a mail survey of New Jersey surgeons. Of 531 respondents, 430 (81%) preferred a traditional inguinal incision approach over a laparoscopic approach (8%). Of 344 general surgeon respondents, 227 (66%) had experience with laparoscopic cholecystectomy, but only 56 (16%) had experience with LH. This latter group had performed only an average of 9.2 laparoscopic herniorrhaphies, with a median of five cases. Most of these 56 surgeons with LH experience indicated a preference for inguinal incision herniorrhaphy although 19 surgeons who had performed 10 or more LH cases showed a slight preference for LH (11 to 8). The primary reasons for choosing LH included "less pain" and "quicker recovery." The primary reasons for choosing inguinal incision herniorrhaphy included having a "better known procedure" and avoiding general anesthesia. Our survey indicates that the laparoscopic approach to inguinal hernia repair has currently accumulated few proponents in the surgical community since many surgeons are waiting for more data on the procedure.

Hernia, Inguinal↗

PubMed1993

Pancreatic cystogastrostomy by combined upper endoscopy and percutaneous transgastric instrumentation.

Minimally invasive endoscopic and radiologic techniques have been reported for internal gastric drainage of pancreatic pseudocysts but these have significant technical limitations. A purely endoscopic approach to cystogastrostomy provides limited access for instrumentation and hemostasis. Radiologically-guided percutaneous techniques cannot regularly provide an adequately wide cystogastrostomy opening. Reported is a patient who had a pancreatic cystogastrostomy performed using a minimally invasive surgical approach combining upper endoscopy and percutaneous transgastric surgical instrumentation. The upper endoscope essentially served as a camera. A percutaneous endoscopic gastrostomy tube served as a port for inserting laparoscopic instruments into the stomach. The laparoscopic instruments were used to create a 1.5 cm cystogastrostomy opening similar in size to what could be created by an open abdominal approach. The laparoscopy instruments provided good tactile feedback and excellent hemostatic control. Avoiding an open abdominal procedure shortened postoperative recovery and reduced patient discomfort. Although the pseudocyst recurred once, the same procedure was performed again and there has not been a recurrence for 10 months. The authors conclude that this minimally invasive surgical procedure provides an excellent alternative approach for internal drainage of selected pancreatic pseudocysts.

Adult↗

PubMed1992

Upper extremity occlusive arterial disease after radiotherapy for breast cancer.

Upper extremity arterial occlusive disease is a rare complication of radiation therapy for breast cancer. We present the case of a 74 year old woman who developed upper extremity ischemia 32 years after mastectomy and radiation therapy. Arteriography identified a stenotic proximal brachial artery lesion within the previous radiation field. Balloon angioplasty was unsuccessful. An axillo-brachial bypass relieved the ischemia and is still patent after 24 months. The previous literature shows that arterial bypass procedures have been uniformly successful in this circumstance. Little experience has been reported with balloon angioplasty for these lesions.

Aged↗

PubMed1992

Arterial vasopressin for control of bleeding from a stapled intestinal anastomosis. Report of two cases.

Postoperative bleeding from a stapled intestinal anastomosis is a rare complication. In previously reported cases, the bleeding either ceased spontaneously or required reoperation for direct control. We report two cases in which the bleeding was controlled using an intra-arterial vasopressin infusion. To our knowledge, this technique has not been previously reported for management of this problem. We had initial concerns about creating ischemia at the anastomosis, which could lead to disruption. Neither patient demonstrated subsequent problems with the anastomosis. Intra-arterial vasopressin infusion appears to be an effective method for controlling bleeding from a stapled intestinal anastomosis and can avert the need for reoperation.

Aged↗

PubMed1992

Transfusion guidelines for cardiovascular surgery: lessons learned from operations in Jehovah's Witnesses.

Patients undergoing cardiovascular surgery are among the top users of homologous blood transfusion (HBT). Awareness of the risks of disease transmission and immune system modulation from HBT has prompted us to find alternatives such as autologous predonation (APD) and intraoperative autotransfusion (IAT). However, these latter options are not appropriate for all patients. We reviewed our experience with 59 Jehovah's Witness patients who underwent 63 elective cardiovascular procedures without either HBT or APD to determine the safety of operation without these modalities and to develop revised maximum surgical blood-ordering schedule guidelines for cardiovascular surgery. Estimated blood loss averaged 870 ml, but one third to one half of losses were replaced by IAT. IAT was not needed in lower extremity bypass operations in which the estimated blood loss was less than 150 ml. Three of 59 patients died (5.1%), but only one died of operative bleeding complications. We conclude that (1) elective cardiovascular operations can be done safely without the use of either HBT or APD, (2) HBT is not necessary in leg bypass procedures, and (3) maximum surgical blood-ordering schedule guidelines for HBT in major cardiovascular operations can be reduced to near zero by the use of intraoperative autotransfusion and acceptance of a postoperative hemoglobin nadir of 7.0 gm/dl.

Blood Loss, Surgical↗

PubMed1992

Is hemoglobin level alone a reliable predictor of outcome in the severely anemic surgical patient?

The relationship between outcome and hemoglobin (Hgb), oxygen extraction ratio (ER), history of cardiac, renal, pulmonary, and/or hepatic disease, diabetes, malignancy, sepsis, hypertension, and active bleeding was analyzed in 47 patients with severe anemia (Hgb less than 7.0 gm/dl, mean = 4.6 +/- .2 gm/dl) to evaluate the effect of Hgb on survival and to look for other predictors of outcome. All patients had refused blood transfusion on religious grounds and were participants in a randomized, controlled study of the blood substitute Fluosol DA-20 per cent. Patients were analyzed as a group and after stratifying by Hgb into four levels: (Hgb less than 3.0 gm/dl, N = 7; Hgb less than 3.5 gm/dl, N = 12; Hgb less than 4.0 gm/dl, N = 17; Hgb less than 4.5 gm/dl, N = 23) and by ER into two levels of less than 50 per cent and greater than 50 per cent. Only Hgb, ER, sepsis and active bleeding were predictors of outcome, with sepsis being the only significant, independent predictor of outcome at all levels (P less than .01). Active bleeding was a predictor for levels of Hgb below 4.0 gm/dl. Hgb level alone was a significant predictor only at levels below 3 gm/dl (P less than .05). Extraction ratio interacted with Hgb only below 3 gm/dl (P less than .05). Multiple independent factors influence outcome in the severely anemic patient, the strongest being sepsis and active bleeding. Prevention of sepsis and early intervention to stop bleeding should improve survival in the patient who refuses transfusion.

Anemia↗

PubMed1992

Hemoductal pancreatitis.

Gastrointestinal tract hemorrhage from rupture of the splenic artery into the pancreatic duct is unusual. This obscure cause of intermittent gastrointestinal tract bleeding should be suspected when the more common causes of bleeding have been ruled out. Duodenoscopy carried out during active hemorrhage may reveal blood coming from the papilla of Vater. Coeliac arteriography will show the pathognomonic findings and confirm the diagnosis. We have treated three patients who had chronic pancreatitis and who developed pseudocyst formation and pseudoaneurysms of the splenic artery. The pseudoaneurysm ruptured into the duct of Wirsung, causing obscure upper-gastrointestinal bleeding. Treatment was distal pancreatectomy and splenectomy, including the pseudoaneurysm and pseudocyst. A review of the literature suggests that three different types of bleeding into the pancreatic duct can occur. The cause of each is described.

Adult↗

PubMed1991

Serial duplex scans elucidate the evolving hemodynamics of distal arteriovenous fistulas.

Arteriovenous fistulas at the distal anastomosis have been suggested to improve the patency of prosthetic femorocrural bypasses. We have followed nine patient with bypasses to the crural vessels and distal arteriovenous fistulas using physical examination, pulse volume recordings, and segmental pressure indices. Duplex scans of the distal anastomosis were employed to determine the contribution of arterial and venous outflow to total graft flow. Early graft patency was achieved in all patients. One patient went on to amputation at one week postoperatively for progressive ischemia despite a patent graft. The other eight patients achieved successful revascularization. Healing of ulcers, relief of rest pain, the presence of palpable pulses, good pulse wave amplitude, and normal pressure indices are consistent findings as long as the bypass is patent. One patient died on the fourth postoperative day from a myocardial infarction. The remaining patients have been followed from one to 23 months with follow-up examination every three to four months. Sequential duplex scans show that flow continues into distal arteries while venous outflow diminishes. This corresponds to a reduction in the diameter of the outflow veins while the caliber of arterial runoff is maintained. Patency has been achieved up to 23 months with a mean of 12 months. Venous outflow occlusion precedes graft thrombosis by two to 15 months. Graft occlusion has uniformly necessitated amputation. It may be possible to improve long-term graft patency and limb salvage by surgical revision of the distal anastomosis to reestablish venous outflow.

Aged↗

PubMed1990

Intraoperative transcutaneous oxygen tension criteria for completion arteriography.

During the past three years, we studied the value of transcutaneous oxygen monitoring in 28 lower extremity vascular bypass procedures. In 21 reconstructions, a rapid rise in the transcutaneous oxygen tension following reperfusion was indicative of a patent graft and patent runoff vessels. Inadequate revascularization was identified in three of four patients in whom transcutaneous oxygen tension failed to rise following femorodistal arterial bypass (positive predictive value 75%). A normal intraoperative transcutaneous oxygen tension study following femorodistal bypass had a negative predictive value of 95%. The overall accuracy was 91%. Transcutaneous oxygen tension monitoring during lower extremity vascular bypass procedures is useful in assessing the success of revascularization and may be used to select which patients should undergo completion arteriography as opposed to those in whom an arteriogram is not essential.

Anastomosis, Surgical↗

PubMed1990

Elective surgery without transfusion: influence of preoperative hemoglobin level and blood loss on mortality.

To clarify the widespread practice of preoperative transfusion to attain a 10 g/dL level of hemoglobin, the relationship between preoperative hemoglobin level, operative blood loss, and mortality was studied by analyzing the results of 113 operations in 107 consecutive Jehovah's Witness patients who underwent major elective surgery. Ninety-three patients had preoperative hemoglobin values greater than 10 g/dL; 20 had preoperative hemoglobin levels between 6 to 10 g/dL. Mortality for preoperative hemoglobin levels greater than 10 g/dL was 3 of 93 (3.2%); for preoperative hemoglobin levels between 6 to 10 g/dL, mortality was 1 of 20 (5%). Mortality was significantly increased with an estimated blood loss of greater than 500 mL, regardless of the preoperative hemoglobin level (p less than 0.025). More importantly, there was no mortality if estimated blood loss was less than 500 mL, regardless of the preoperative hemoglobin level. From these data, we conclude that: (1) Mortality in elective surgery appears to depend more on estimated blood loss than on preoperative hemoglobin levels; and (2) Elective surgery can be done safely in patients with a preoperative hemoglobin level as low as 6 g/dL if estimated blood loss is kept below 500 mL.

Adolescent↗

PubMed1990

Fluosol DA-20 in the treatment of severe anemia: randomized, controlled study of 46 patients.

We evaluated the safety and efficacy of Fluosol DA-20% (FDA) as a blood substitute in the treatment of severe anemia. Thirty-six patients received either FDA (n = 21) or crystalloid/hydroxyethyl starch (CHS) (n = 15) as part of a randomized, controlled trial. Ten patients received FDA as part of a humanitarian protocol. All were Jehovah's Witnesses who refused transfusion, had bled recently, and had average Hgb levels of 4.3 g/dl. After pulmonary artery catheter insertion, each patient was infused with CHS to attain a pulmonary artery wedge pressure (WP) of 10 to 18 mm Hg. FDA was given as a one-time dose of 30 ml/kg. Data were collected at baseline, 12, 24, and 48 h. None of the patients with negative reactions to a 0.5-ml test dose of FDA had adverse reactions to the subsequent infusion. The plasma or dissolved component of oxygen content was significantly higher in the FDA group at 12 h (FDA group 1.58 +/- 0.47 ml/dl, control group 1.01 +/- 0.31 ml/dl, p less than .02, t-test). Nineteen patients died: 12 (37.5%) FDA, seven (46.6%) control. The difference was not significant. We conclude the following: a) FDA can be given safely to severely anemic patients in doses of 30 ml/kg; b) FDA significantly increased the dissolved component of oxygen content after 12 h but the effect did not persist; c) severely anemic patients can survive without transfusion although mortality is high. In this study, inability of FDA to sustain increased oxygen content was due in part to the rapid elimination of FDA and also to the limited amount given.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗