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Biomedical subjects

R J Gusberg

Publications and source records attributed to R J Gusberg.

At least 37 records · Page 2Linked to original sources
PubMed1990

Fenestration revisited. A safe and effective procedure for descending aortic dissection.

Although it was initially performed in 1935, aortic fenestration has been infrequently employed and reported in recent years. We have continued to use fenestration for descending aortic dissection with complicating organ ischemia (lower-extremity ischemia, renal ischemia, and paraplegia). Our technique involves complete transection of the infrarenal abdominal aorta, removal of a generous intimal flap proximally, and reconstitution of layers distally. We report our experience with 12 patients, all of whom survived the operative procedure. Nine patients were discharged from the hospital, and with a mean follow-up of 6.8 years, 7 are still alive. Fenestration immediately restored organ perfusion in all but 1 of the patients, and no patient died of late rupture. We recommend fenestration for descending aortic dissection in patients presenting with organ ischemia. Fenestration is not recommended for acute dissection with rupture or for chronic enlarging dissection.

Adult↗
PubMed1990

Captopril renal scintigraphy--an advance in the detection and treatment of renovascular hypertension.

Despite the risks associated with renovascular hypertension and the durable benefits of revascularization, the detection of patients with renovascular hypertension and the selection of those who will benefit from interventional therapy remains a challenge. We have previously documented the reliability of captopril renal scintigraphy in predicting angiographically significant renal artery stenosis in patients suspected of having renovascular hypertension. In the present study we report our recent experience with this noninvasive technique in predicting outcome after revascularization. Captopril renal scintigraphy involves the administration of 50 mg of captopril 3 hours after a baseline technitium-99m diethylenetriaminepentaacetic acid renal scan and 1 hour before a repeat captopril renal scintigraphy scan. Nineteen of the last 70 patients with clinically suspected renovascular hypertension undergoing captopril renal scintigraphy had abnormal renal scan outcomes, and 17 had a decrease in flow or function after captopril (positive captopril renal scintigraphy). Eight of these 17 with abnormal findings on captopril renal scintigraphy underwent revascularization, and the hypertension was cured or improved in six of the eight: two of three after surgical bypass grafting and four of five after angioplasty. In the seven surviving patients with abnormal renal scan results but no change with captopril (negative captopril renal scintigraphy), improvement in hypertension after treatment occurred in only one: one of two after nephrectomy, zero of three after bypass surgery, and zero of two after angioplasty (p less than 0.05). We conclude that captopril renal scintigraphy is an accurate predictor of hypertension response to revascularization. Further evaluation of this new noninvasive technique for assessing patients with suspected renovascular hypertension appears warranted.

Aged↗
PubMed1990

Does visceral ischemia play a role in the pathogenesis of acute acalculous cholecystitis?

Acute acalculous cholecystitis is a virulent disease of uncertain etiology observed most commonly in critically ill patients. Although the precise mechanism is unknown, the most commonly postulated theories regarding its pathogenesis are bile stasis, sepsis, and ischemia. The role of ischemia in this process, whose etiology is multifactorial, has been difficult to elucidate. Consequently, we report two patients who developed acute acalculous cholecystitis without apparent risk for the disease other than severe visceral atherosclerosis. Both patients had symptomatic mesenteric vascular disease requiring revascularization and developed fulminant acalculous cholecystitis temporally related to exacerbation of their visceral ischemia. These cases suggest that patients with visceral atherosclerosis may be at increased risk for acute acalculous cholecystitis, perhaps due to impaired mucosal resistance when other factors, such as bile statis and sepsis, are also present.

Acute Disease↗
PubMed1990

The effects of early treatment of hereditary tyrosinemia type I in infancy by orthotopic liver transplantation.

Two infants with hereditary tyrosinemia secondary to fumarylacetoacetate hydrolase (FAH) deficiency underwent orthotopic liver transplantation at 14 and 16 weeks of age due to poor clinical and biochemical response to medical therapy. Prompt clearance of abnormal metabolites with improved mental alertness and appetite occurred with minimal perioperative complications. Both infants tolerated rapid institution of normal diets and have shown progressive growth and development in the first 36 months after transplantation. Early liver transplantation should be considered as an option for infants with certain inherited metabolic disorders with poor prognosis, such as tyrosinemia type I, who fail to respond to medical therapy.

Amino Acid Metabolism, Inborn Errors↗
PubMed1989

Endoscopic sclerotherapy: a risk factor for splanchnic venous thrombosis.

Endoscopic sclerotherapy has been widely advocated as primary therapy for patients surviving hemorrhage from esophageal varices. The potential for endoscopic sclerotherapy to limit subsequent surgical options remains unclear. The following study was undertaken to assess the endoscopic sclerotherapy-related incidence of splanchnic venous thrombosis in patients undergoing surgery for variceal bleeding. We retrospectively identified 27 patients who underwent portosystemic shunting after an episode of variceal hemorrhage documented by endoscopic examination. Eleven patients underwent endoscopic sclerotherapy before portosystemic surgery for shunting. Among the patients undergoing prior endoscopic sclerotherapy, 6/11 had partial splanchnic venous thrombosis at surgery compared with 2/16 in the non-endoscopic sclerotherapy group. This difference was statistically significant. Only one of the eight patients with splenic or portal vein thrombosis detected at surgery showed signs of the condition when an angiograph was performed. Endoscopic sclerotherapy appears to impose a significant risk for splanchnic venous thrombosis. This complication, not reliably detected by angiographic means, may limit the operative options and long-term outcomes of patients in whom endoscopic sclerotherapy fails.

Endoscopy↗
PubMed1988

Variceal bleeding, hypersplenism, and systemic mastocytosis. Pathophysiology and management.

Systemic mastocytosis is characterized by an abnormal proliferation of tissue mast cells. Though rarely a surgical disease, it occasionally presents as variceal bleeding secondary to portal hypertension. Ultrastructural studies of the liver and spleen and portal pressure measurements support the hypothesis that a perisinusoidal intrahepatic fibrosis is responsible for the increased portal pressure. When variceal bleeding complicates systemic mastocytosis, shunt surgery is indicated, with the type of shunt dictated by both hematologic and hemodynamic issues. Satisfactory blockade of histamine release can be achieved preoperatively by disodium cromoglycate and/or histamine antagonists to obviate any systemic effects precipitated by shunting of mast cell-rich splenic blood into the systemic circulation.

Adult↗
PubMed1988

A simple index to estimate the likelihood of bacterial infection in patients developing fever after abdominal surgery.

To identify predictors of bacterial infection in patients developing postoperative fever, we prospectively studied 434 adults who underwent abdominal surgery. Of the 434 study patients, 163 (38%) developed postoperative fever (38.1 degrees C [100.6 degrees F] or greater) and 26 (16%) of the febrile patients were found to have bacterial infection. Logistic-regression analysis showed that postoperative infection was associated with a WBC count of less than 5000 or greater than 10,000/mm3, a BUN of 15 mg/dl or greater, and fever onset after the second postoperative day. A predictive index, constructed from these three features, created a useful gradient for estimating the likelihood of postoperative infection. In patients with zero, one, two or three of the index features, the proportions having infection were 2 per cent (1/50), 14 per cent (12/88), 45 per cent (10/22), and 100 per cent (3/3), respectively (P less than 0.0001). This simple index, which uses readily available clinical data, may help reduce the cost of postoperative care by identifying patients with a low probability of infection in whom cultures, imaging studies, and empirical antibiotics do not appear necessary. Thorough diagnostic evaluation in patients with two or more index features may also reduce delay in the detection and treatment of postoperative infection. The predictive value of this index should be validated in a new patient set, however, before widespread application of the index is warranted.

Abdomen↗
PubMed1987

Aortic thrombosis with paraplegia: an unusual consequence of blunt abdominal trauma.

Aortic thrombosis occurring after blunt abdominal trauma is a rare but recognized event. Most of these patients present with progressive and profound neurologic compromise. Successful management requires early diagnosis, maintenance of hemodynamic stability, and prompt revascularization. Despite appropriate management a large percentage of these patients (unprotected by heparin or collateral vessels) will remain paraplegic.

Abdominal Injuries↗
PubMed1987

Histamine levels and cardiovascular responses during splenectomy and splenorenal shunt formation in a patient with systemic mastocytosis.

Systemic mastocytosis is a rare disorder characterised by the infiltration of many tissues by abnormal numbers of mast cells. Life-threatening episodes of bronchospasm and hypotension are common in response to a variety of triggers which cause mast cell degranulation. We present the case history of a patient with severe mast cell disease who successfully underwent splenectomy and portocaval anastomosis. Peri-operative therapy was directed towards mast cell stabilisation, and histamine-releasing drugs were avoided. Cardiovascular data, together with blood histamine levels and thrombin times, indicated that mast cell degranulation did not occur. A review of the current literature concerning mast cell disease as it relates to anaesthesia is presented and suggestions for the safe management of such cases are given.

Adult↗
PubMed1985

Results of aortic grafting in occlusive vs aneurysmal disease.

Recent demographic and biochemical studies have suggested that there may be significant differences in the population of patients undergoing reconstruction for an aortic aneurysm (AA) or atherosclerotic occlusive disease (OCC) of the abdominal aorta. The purpose of this retrospective study was to compare the results of aortic surgery in these different patient groups. One hundred three patients undergoing aortic grafting were reviewed. Twenty-four patients underwent reconstruction for OCC, 65 selectively for asymptomatic aneurysms (EAA), and 14 for ruptured aortic aneurysms (RAA). The mean age for OCC patients (54 years) was significantly lower than that for EAA (68 years) or RAA patients (71 years). Patients with AA were predominantly male (92%) compared with those with OCC (62%). Despite the age and sex differences, there were no significant differences between the groups in the incidence of cardiac disease, hypertension, smoking history, diabetes mellitus, or renal or pulmonary disease. In addition, there were no significant intraoperative differences in terms of operative and clamp times, fluid administration, urine output, hypotension, or subsequent postoperative morbidity and mortality. We conclude that despite AA and OCC patients being demographically distinct, there is essentially no difference in elective aortic bifurcation graft surgery between these two populations.

Age Factors↗
PubMed1983

Gastrointestinal hemorrhage from pseudoaneurysms in pancreatic pseudocysts.

Gastrointestinal hemorrhage secondary to hemosuccus pancreaticus is a rare condition that poses a significant diagnostic and therapeutic challenge. It is reported to occur most commonly in the setting of acute or chronic pancreatitis with rupture of pseudoaneurysms of the spleen or hepatic artery into the pancreatic duct. In this report three such cases have been reported. Abdominal ultrasound and CT scanning can noninvasively define pancreatic pseudocysts with a high degree of accuracy. Real-time ultrasonography may document a pulsatile pseudoaneurysm. Radionuclide arterial scanning, by demonstrating pooling of blood in the area of a pseudocyst, can point to the source of bleeding in patients with pancreatitis and gastrointestinal hemorrhage. Selective celiac angiography, however, is the only diagnostic test that can definitively outline a pseudoaneurysm and demonstrate its rupture into a pseudocyst or into the pancreatic duct. Pancreatic resection including excision of the pseudoaneurysm and pseudocyst (when present) is the treatment of choice. In cases where resection is not possible, ligation of the artery proximal and distal to the pseudoaneurysm and drainage of the pseudocyst into the gastrointestinal tract is an acceptable alternative procedure. Although intraarterial catheter embolization of the bleeding vessel can be a lifesaving procedure in these very sick patients, subsequent resection of the lesion is warranted as the definitive treatment.

Adult↗
PubMed1981

Percutaneous transtubal scintigraphic assessment of patency of peritoneovenous shunts.

Peritoneovenous shunts have been widely used in the management of patients with ascites when medical therapy has failed. Shunt malfunction is a frequent complication. Direct injection of a small amount of Tc-99m-sulfur colloid into the afferent limb of the shunt allows prompt, accurate determination of shunt patency while avoiding some of the hazards and pitfalls of previously described techniques.

Humans↗
PubMed1979

Obturator canal bypass grafts for septic lesions of the femoral artery.

Infection of the femoral artery results in false aneurysm formation and hemorrhage unless appropriate reconstructive measures are taken. We reviewed ten such cases managed by obturator canal bypass with autogenous saphenous vein. The graft maintained viability of the extremity in every case in the early postoperative period. One death occurred related to cardiac disease, and there was one late failure. This experience confirms the usefulness of the obturator canal as a method for bypass of the infected femoral artery.

Adolescent↗