Biomedical subjects
Publications and source records attributed to R E Welling.
With the aid of CT scans, lower GI series, and observation, we correctly diagnosed and managed nonoperatively an intramural hematoma of the ascending colon.
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In a review of 35 patients undergoing local thrombolysis using selective infusion of low-dose streptokinase, the overall success rate was 43%. Streptokinase appears to be most effective in occlusion of native arteries, in high-flow segments, and in autogenous saphenous vein grafts. Local streptokinase was least effective in occluded prosthetic grafts in the femoropopliteal segment (19% success). Distal embolization and progression of thrombosis of the distal arterial tree may occur while the patient is undergoing local thrombolysis and may result in limb loss. Hence, local thrombolysis is not recommended when surgical treatment is an alternative. Despite the low dose, systemic fibrinolytic effects and hemorrhagic complications were common occurrences; hence, routine hematologic monitoring is mandatory in patients undergoing lytic therapy with local infusion of streptokinase.
Seven patients--six of whom died--underwent surgical repair of a ruptured abdominal aortic aneurysm and developed postoperative ischemic colitis. All patients were male, with a mean age of 62 years. Resection of the necrotic colon with a colostomy was necessary within the first postoperative week for the six patients who did not survive and on the 40th postoperative day for the patient who lived. The colon is vulnerable to ischemic necrosis after an aortic rupture because of tissue hypoperfusion and impaired mesenteric artery circulation due to preexistent occlusive disease. In high-risk patients, fiberoptic colonoscopy and examination of stool for occult blood, with immediate abdominal exploration, if necessary, are important in the early postoperative period. Symptoms may develop insidiously when tissue damage is limited to the mucosal layer, but delay in resecting the ischemic segment allows for the extension of necrosis, with perforation.
A case of total occlusion of the cervical internal carotid artery secondary to vasculitis is presented. Although vasculitis rarely causes total occlusion of the internal carotid artery, it directly contributed to a left hemispheric stroke in our patient. In the absence of the usual etiologic factors for internal carotid artery occlusion, vasculitis should be considered.
Torsion of the gallbladder is rare. However, the surgeon should be aware of it and that unusual presentations in the elderly make early diagnosis very difficult. A 100-year-old white female presented with right-sided abdominal pain and was found to have acute torsion of the gallbladder. The clinical picture, diagnostic tests, and operative findings are outlined. Serial evaluations of the patient's condition and a high index of suspicion are essential elements for prompt recognition and early surgical management.
A case of pseudoaneurysm in the extracranial internal carotid artery secondary to blunt trauma is presented to corroborate reports of aneurysmal formation in association with ipsilateral mandibular fracture. Because of the possibility of rupture or the development of neurologic symptomatology due to embolization, pseudoaneurysms of the cervical internal carotid artery should be repaired. We recommend use of the autogenous interposition vein graft to restore arterial continuity.
From January 1980 until May 1983, 24 patients had surgical exploration of the carotid bifurcation for suspected recent total occlusion of the internal carotid artery (ICA). All patients had recent onset of neurologic symptoms related to the ipsilateral cerebral hemisphere. Selective carotid angiography determined preoperative total occlusion of the ICA. Because surgery failed to reopen the ICA in nine patients, they had endarterectomy of the external carotid artery. Fifteen patients had initially successful thromboendarterectomy of the ICA. Prior to patient dismissal, patency was documented by B-mode ultrasound or digital subtraction angiography (DSA). All 15 patients had another B-mode ultrasound scan or DSA at least 45 days after thromboendarterectomy. On reexamination four ICAs were reoccluded, but only one patient became symptomatic. There were no operative deaths and no increase in preoperative neurologic deficits. The natural history of patients with total occlusion of the ICA is variable. The most important factor influencing a therapeutic decision is the patient's neurologic status. This study supports an aggressive, early surgical intervention for recent total occlusion in carefully selected patients.
Carotid artery aneurysms are rare, however, serious complications may result--namely, rupture, thrombosis, or emboli. Five distinct clinical types of aneurysms are reported with different symptoms and treatment. Fusiform, saccular, false, and mycotic aneurysms are best treated with interposition autogenous vein grafting. Spontaneous dissection aneurysms are best treated initially with anticoagulation and follow-up angiography. Recanalization is the usual result. Meticulous surgical technique to prevent perioperative emboli is essential to prevent central nervous system complications.
TAO is a distinct, pathologic, and clinical disease process. Its diagnosis can be arrived at with a reasonable degree of certainty by the clinical history, angiographic findings, and pathology. Tobacco plays a very important part in the etiology of the disease process and must be completely avoided in any form for successful treatment. Four-extremity arteriography is recommended to assess the present nature of the disease and for a comparison at a later date. Direct arterial surgery is seldom feasible because of the distal and segmental nature of TAO. Sympathectomy can be helpful if combined with elimination of tobacco and quiescence of the disease. Meticulous local therapy to the ischemic tissue with control of infection and precise amputation if necessary is extremely important.
During the past 20 years, 163 patients had 194 operations for obliterative arterial disease of the upper extremity. Of these, 68 had neurological symptoms primarily that were associated with arterial obstruction of the first portion of the subclavian artery. The remaining 95 patients had ischemic symptoms of the upper extremity, namely, intermittent claudication of the arm or ischemic necrosis of the fingers. There were 95 procedures performed on 90 patients with diminished or absent brachial blood pressures. There were 89 cervical sympathectomies performed on patients whose brachial pressures were equal to the contralateral arm. When sympathectomy was done, results were excellent in patients who had a rise in skin temperature confirmed preoperatively by reflex vasodilation studies. An aggressive approach with early diagnostic arteriography and appropriate surgical therapy is indicated in patients with ischemia to the upper extremity.
Complete dislocation of the knee is rare, but is frequently associated with popliteal artery disruption. Prompt recognition and early revascularization are paramount for a successful and functional result. Arteriography is recommended in all cases of complete dislocation of the knee. Excision of the damaged arterial segment with saphenous vein bypass grafting is the treatment of choice. Associated venous and nerve injuries should be recognized and repaired early. Liberal use of compartment decompression procedures give better long-term results.
Idiopathic retroperitoneal fibrosis with duodenal obstruction is a rarely reported clinical entity. The presenting symptoms of nausea, vomiting, weight loss, and progressive fatigability can be easily overlooked if attention is focused on the more prominent symptoms of low back and flank pain. Duodenal obstruction can present several months after the initial diagnosis of retroperitoneal fibrosis. Nutritional support before surgical correction is imperative.
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A 50-year old woman was admitted with a mass in the anterior triangle of the neck. Because of interpretation of a needle biopsy specimen as undifferentiated adenocarcinoma, a radical excision of cervical lymph nodes was performed and the specimen showed metastatic adenocarcinoma suggestive of carcinoid tumor. Four months later the patient developed an abdominal mass that turned out to be large mesenteric lymph nodes involved in carcinoid tumor, the primary lesions being in the terminal ileum. Following resection of all visible tumor, the patient has remained symptomatically and chemically well for 15 months. No previous case of carcinoid tumor metastatic to the neck can be found.
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Explore the source record for details and available documents.