Search PubMed⌕ Search

Biomedical subjects

W D Rappaport

Publications and source records attributed to W D Rappaport.

At least 19 recordsLinked to original sources
PubMed1999

Nonsurgical causes of pneumoperitoneum.

The radiographic manifestation of free air in the peritoneal cavity suggests serious intra-abdominal disease and the need for urgent surgical management. Yet, about 10% of all cases of pneumoperitoneum are caused by physiologic processes that do not require surgical management. We retrospectively reviewed cases of nonsurgical causes of pneumoperitoneum at the 2 teaching hospitals of a university medical center between January 1990 and December 1995. Successful management by observation and supportive care without surgical intervention was defined as the diagnostic feature of nonperforation. Failure of a laparotomy to delineate a surgical cause or to result in a reparative procedure is congruent with a nonsurgical cause of pneumoperitoneum. During this period, 8 patients (6 men and 2 women; mean age, 61 years) were identified with nonsurgical causes of pneumoperitoneum. Two patients underwent negative laparotomy, and the other 6 were successfully managed nonoperatively and discharged from the hospital. In 6 patients, a cause of the pneumoperitoneum was identified. The causes may be grouped under the following categories: postoperatively retained air, thoracic, abdominal, gynecologic, and idiopathic. In our review of the literature, 61 of 139 reported cases underwent surgical treatment without evidence of perforated viscus. To avoid unnecessary surgical procedures, both primary medicine physicians and surgeons need to recognize nonsurgical causes of pneumoperitoneum. Conservative management is warranted in the absence of symptoms and signs of peritonitis.

Academic Medical Centers↗
PubMed1997

Lower extremity iatrogenic nerve injury due to compression during intraabdominal surgery.

BACKGROUND: latrogenic nerve injury due to poor positioning and external compression is a common surgical complication. However, sciatic neuropathy from external compression and femoral nerve injury after self-retaining retraction are less-published complications. METHODS: Surgical Morbidity and Mortality Reports from 1986 through 1995 were reviewed to identify femoral and sciatic neuropathies following intraabdominal vascular and general surgeries. RESULTS: Two sciatic and 5 femoral neuropathies were reported, an incidence of approximately 0.17% of abdominal cases. Sciatic injuries were attributed to external compression, whereas femoral neuropathies were due to compression by self-retaining retraction. The 3 female and 4 male patients had a mean age of 53.4 years, and no patient had a prior history of peripheral neuropathy. Mean operating time for sciatic injuries was 8.2 hours, versus 4.3 hours for femoral neuropathies. Both patients with sciatic neuropathy had complete resolution of symptoms, compared with 1 femoral neuropathy patient. Two femoral neuropathies were permanent, 1 had partial resolution and 1 had improvement at 4 months but was lost to follow-up. CONCLUSIONS: Sciatic and femoral compression neuropathies are rare but serious complications of abdominal surgery. When retracting in the deep pelvis, consideration should be given to using small, well-padded retractor blades and repositioning these regularly. Prevention of sciatic nerve compression requires careful padding of the table surface, especially for longer cases.

Abdomen↗
PubMed1997

Site-specific pharmacokinetics and pharmacodynamics of intramuscular meperidine in elderly postoperative patients.

OBJECTIVE: To examine and compare the pharmacokinetics and pharmacodynamics of meperidine when administered intramuscularly at gluteal and deltoid sites in elderly postoperative patients. DESIGN: Prospective, randomized investigation. SETTING: Tertiary care university teaching hospital. PATIENTS: Fourteen patients 60 years of age or older who were undergoing general surgery. INTERVENTION: A single dose of meperidine 0.75 mg/kg given intramuscularly at either a deltoid or gluteal site. MAIN OUTCOME MEASURES: Pharmacokinetic (based on concentration-time curves) and pharmacodynamic (i.e., pain scales, need for additional pain medication) comparisons were made, based on site of meperidine injection. RESULTS: No statistically significant differences were found in the maximum plasma concentration, volume of distribution, or clearance of meperidine by site of injection. Substantial interpatient variability in pharmacokinetic parameters was noted for both sites (range of maximum concentrations: 191-500 ng/mL gluteal, 166-374 ng/mL deltoid). Although pain scores were similar for the two groups, four of the patients in the group given gluteal injection required additional breakthrough pain management within 4 hours of meperidine injection compared with one patient in the group given deltoid injection. CONCLUSIONS: There is no obvious relationship between meperidine pharmacokinetic and pharmacodynamic parameters, regardless of intramuscular injection site. Breakthrough pain is common when patients are given intramuscular injections postoperatively, particularly when the gluteal route is used. When meperidine is used for analgesia in elderly postoperative patients, consideration should be given to more rapid and predictable routes (e.g., intravenous injection) of meperidine administration.

Aged↗
PubMed1996

Clinical presentation and management of iatrogenic colon perforations.

BACKGROUND: Because iatrogenic colonic perforation is uncommon, surgical management of this complication has been based on the civilian trauma experience. In this study, we determine the incidence, clinical presentation, and management of colonic perforations resulting from colonoscopy or barium enema. PATIENTS AND METHODS: The medical records of all patients with colorectal perforations due to barium enema or colonoscopy seen over a 5-year period were reviewed. RESULTS: Twenty-one patients, 12 males and 9 females aged 66 +/- 16 years, undergoing evaluation for polyps and bleeding (11), diverticulosis (4), diarrhea (2), or miscellaneous indications (4) sustained colonic perforation from colonoscopy (18; 0.20%) or barium enema (3; 0.10%). Abdominal pain, 66% (13), and fever, 24% (5), were the most frequent symptoms encountered and extraluminal air, 67% (14), the most common radiologic finding. The site of perforation was the rectosigmoid in 62% (13) of patients. Eighteen patients underwent surgery; 11 within 24 hours (group I) and 7 patients within 6.0 +/- 4 days (group II). Fifty percent (9 of 18) had primary repair or resection with anastomosis without mortality. Of the 6 patients initially treated nonoperatively, 3 subsequently underwent surgery. Both deaths, one in group I and one in group II, occurred in patients who had colonic diversion for perforation following colonoscopy. CONCLUSION: We conclude that in the absence of significant contamination either primary repair or resection and anastomosis can be performed with acceptable morbidity for iatrogenic perforations of the colon.

Adolescent↗
PubMed1995

Cellular origin and rate of endothelial cell coverage of PTFE grafts.

To determine the origin, cell type present, and rate of endothelial cell coverage of PTFE grafts, 5-cm segments of 4-mm-diameter, 60-microns PTFE grafts were implanted end-to-end bilaterally in the carotid arteries of greyhound dogs. An external jugular vein wrap was applied to the outer surface of one of the PTFE grafts; the contralateral PTFE graft, which was unwrapped, served as its control. Two dogs each were sacrificed at 3, 5, 7, 14, 21, 28, and 35 days postimplantation. Anastomotic endothelial ingrowth was analyzed using scanning electron microscopy. Microvessel ingrowth was documented in longitudinal H&E sections. Cell identity was established by immunohistochemistry with factor VIII antibody, Ulex europaes, leukocyte common antigen, and antibodies to alpha-actin, desmin, vimentin, and basic fibroblast growth factor. All grafts were patent at the time of harvest. Endothelial cell migration from the native artery adjacent to the anastomosis commenced at 7 days, extended to 5 mm beyond the proximal and distal anastomoses by 14 days and to 1.0 cm by 35 days. Endothelialization of the mid-portion of the wrapped grafts occurred via microvessel ingrowth, a process which began at 7 days. Microvessels reached the luminal surface by 28 days and an endothelial cell monolayer was established by 35 days. Wrapping the external surface of the graft with vein increased the rate of graft healing. Basic fibroblast growth factor was detectable by immunohistochemistry at the vein wrap-graft interface in the first 14 days.

Animals↗
PubMed1995

Aspiration pneumonia following surgically placed feeding tubes.

BACKGROUND: The enteral route is preferred in surgical patients requiring nutritional support; however, controversy surrounds the choice of location of feeding tube placement. Although jejunostomy has been commonly accepted as superior to gastrostomy for long-term nutritional support because of an assumed lower risk of aspiration pneumonia, recent studies suggest that reevaluation of common practices of surgical tube placement is warranted. PATIENTS AND METHODS: We conducted a retrospective chart review of gastrostomy and jejunostomy procedures from 1986 to 1993. Demographic information and complications related to the procedure were reviewed. Aspiration pneumonia was defined as respiratory symptoms, leukocytosis, and infiltrate on chest radiograph. RESULTS: Sixty-nine gastrostomies and 86 jejunostomies were performed during the study period. Six patients were diagnosed with aspiration pneumonia; 2 cases of which occurred with jejunostomy and 4 cases occurred with gastrostomy (P = not significant). CONCLUSIONS: There was no difference in rates of pulmonary aspiration or other complications between gastrostomy and jejunostomy. We suggest that when a surgically placed feeding tube is required, the determination of appropriate procedure be based on clinical factors such as the technical difficulty of the operation or long-term feeding goals.

Enteral Nutrition↗
PubMed1995

Abdominal wall hernias in patients with abdominal aortic aneurysmal versus aortoiliac occlusive disease.

BACKGROUND: This study was undertaken to determine the incidence of ventral incisional hernias (VIHs) and inguinal hernias (IHs) in patients with abdominal aortic aneurysmal (AAA) versus those with aortoiliac occlusive disease (AIOD). PATIENTS AND METHODS: The medical records of 193 patients (128 with AAA and 65 with AIOD) who had undergone elective aortic reconstruction were reviewed to determine the number and location of abdominal wall hernias (AWHs). RESULTS: Forty-one AWHs (28 IHs and 13 VIHs) were detected in patients with AAA compared to 13 (11 IHs and 2 VIHs) in patients with AIOD. There was a significantly greater incidence of VIHs in patients with AAA versus patients with AIOD (10% versus 3%, P < 0.05) and recurrent AWHs (28% versus 19%, P < 0.01), but not of IHs (22% versus 17%). CONCLUSION: Patients with AAA have a higher incidence of VIHs and recurrent AWHs--without a corresponding increase in patient-related risk factors--than patients without aneurysm, suggesting that as yet unidentified etiologic factors may contribute to the development of AWHs in these patients.

Aorta, Abdominal↗
PubMed1994

Factors influencing the safety of colostomy closure in the elderly.

Although colostomy closure is a commonly performed surgical procedure, there remains concern that the attendant risks may be misjudged, especially in the elderly. The purpose of this study was to evaluate the safety of performing colostomy closure and to define the factors that may influence morbidity and mortality in patients over the age of 70. Three hundred seven patients (178 males, 129 females) underwent colostomy closure over a 5-year period. The mean age was 52 years and 84 (27%) of the patients were 70 years or older. The indications for colostomy included diverticulitis, 115 (38%); malignancy, 47 (15%); perforation 35 (11%); trauma, 34 (11%); congenital anomalies, 26 (8%); obstruction, 13 (4%); bleeding, 6 (2%); colovesical fistulae, 6 (2%); polyps, 2 (0.7%); and miscellaneous, 23 (8%). An end colostomy was performed in 193 (63%) patients and a transverse loop colostomy in the remaining 114 (37%). There were no deaths. Complications occurred in 27 (9%) patients: 17 were directly related to colostomy closure (8 wound infections, 3 intraabdominal abscesses, 3 small bowel obstructions, 2 anastomotic strictures, and 1 anastomotic leak) while 10 were nonsurgical. Risk factors statistically associated with increased morbidity included age > 70 years (13% versus 5%), end versus loop colostomy (10% versus 2%), an operative time > 2 hr, and estimated blood loss > or = 500 ml (P < 0.05). ASA classification was only predicative of postoperative complications in patients over 70 years of age. We conclude that although colostomy closure can be performed without mortality, the increased morbidity associated with this procedure in patients 70 years or older necessitates careful preoperative assessment.

Adolescent↗
PubMed1994

Stereotactic fine-needle aspiration cytology of nonpalpable breast lesions: an analysis of 258 consecutive aspirates.

BACKGROUND: The role of stereotactic fine-needle aspiration cytology (SFNAC) in the diagnosis of nonpalpable breast lesions is poorly defined. PATIENTS AND METHODS: Data were prospectively collected from 225 consecutive patients with nonpalpable breast lesions who had aspiration cytology followed by immediate surgical excision. RESULTS: Between 1988 and 1993, 258 such procedures were performed. The results of 84 (33%) were interpreted as benign, 84 (33%) as atypical, 28 (11%) as suspicious for malignancy, and 49 (19%) as malignant. In all, 88 (34%) surgical specimens were malignant. SFNAC had an 80% sensitivity, a 96% specificity, a 91% positive predictive value, and an 89% negative predictive value. There were 18 false-negative and 7 false-positive aspirates. CONCLUSIONS: SFNAC for diagnosing nonpalpable breast lesions is moderately sensitive and highly specific, and has a high positive and negative predictive value. In conjunction with mammography and clinical assessment, the procedure is useful for determining which patients with nonpalpable breast lesions may require surgical biopsy.

Adult↗
PubMed1994

Contraindications and complications of laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is a commonly performed procedure for the removal of symptomatic gallstones. Compared with open cholecystectomy, laparoscopic cholecystectomy is associated with less postoperative pain, earlier discharge from the hospital and a more rapid recovery. However, there are specific contraindications to the procedure, including empyema of the gallbladder, gangrenous cholecystitis, coagulopathy, portal hypertension and peritonitis. Complications from laparoscopic cholecystectomy include common duct injury, bleeding, bile leakage and wound infection. An understanding of these issues allows the family physician to more appropriately select patients for laparoscopic removal of the gallbladder.

Cholecystectomy, Laparoscopic↗
PubMed1993

Impact of adjunctive testing on the diagnosis and clinical course of patients with acute appendicitis.

The diagnosis of acute appendicitis is usually made from the history and physical examination. Recently, abdominal ultrasonography (US), laparoscopy, computerized tomography (CT), and barium enema (BE) have been used in the preoperative evaluation of patients with presumed appendicitis in order to improve the diagnostic accuracy. However, the usefulness of these tests in verifying the diagnosis of appendicitis has not been established. We reviewed the medical records of 203 patients who underwent appendectomy. One hundred patients were surgically treated before 1984 (group I) and 103 patients underwent surgery after 1988 (group II). Patients in group II were more likely to have preoperative US, laparoscopy, CT, or BE (24 in group II versus 3 in group I, p < 0.05). When groups I and II were compared, the rates of perforation (27% versus 20%), normal appendectomy (8% versus 11%), and the interval between admission and operation (12.2 hours versus 10.7 hours) and length of hospitalization (5.0 days versus 5.1 days) were not significantly different. We concluded that although adjunctive testing may be beneficial in selected patients, its routine use in patients suspected of having appendicitis cannot be advocated at present.

Acute Disease↗
PubMed1993

Clinical utilization and complications of sural nerve biopsy.

Surgeons frequently perform sural nerve biopsy as part of the work-up of patients with peripheral neuropathy. The indications for the procedure, therapeutic value, and complications associated with the procedure have received little attention in the surgical literature. A retrospective chart review of 60 patients with the suspected diagnosis of peripheral neuropathy undergoing sural nerve biopsy was performed. Vasculitis was suspected in 29 (48%) patients undergoing biopsy. This diagnosis was confirmed in 6 of the 29 patients and resulted in the alteration of therapy in 31% of patients with this suspected diagnosis. In 27 (45%) patients, the etiology of their peripheral neuropathy was unknown. Twelve (44%) patients in this group had sural nerve pathology; however, no change in therapy was required. Ten patients in our series had associated malignant tumors; some of these patients were diagnosed after referral for sural nerve biopsy. Twenty-five (42%) patients remained undiagnosed after biopsy. Nerve conduction studies were performed in 14 (22%) patients. Thirteen patients with abnormal lower extremity nerve conduction studies had 6 normal and 7 abnormal biopsy results. The one patient with a normal study had a normal nerve biopsy result. There were six (10%) patients with wound infections, seven (12%) patients with delayed wound healing, and three (5%) patients with new onset of chronic pain in the distribution of the sural nerve, for an overall complication rate of 27%. There was no correlation between the preoperative use of antibiotics, type of local anesthetic used, or length of nerve excised and complication rate. We conclude that the complication rate after sural nerve biopsy is significant. Strict criteria should be employed in selecting patients for sural nerve biopsy including a careful neurologic history and physical examination, nerve conduction studies, appropriate work-up for vasculitis if suspected, and implementation of a search for malignancy if this is not apparent. If the diagnosis is still in question, then sural nerve biopsy would seem appropriate, especially in patients with suspected vasculitis.

Adult↗
PubMed1992

Ischemic stricture and perforation. An unusual complication after successful barium reduction of an intussusception.

Intussusception is a common cause of intestinal obstruction in infants. Use of a barium enema affords both diagnostic confirmation and a chance for nonsurgical reduction of the intussusception. While failed hydrostatic reduction is an indication for surgical intervention, delayed complications of hydrostatic reduction have not been described. We present a case of ischemic stricture and perforation developing after the successful reduction of an intussusception.

Barium Sulfate↗
PubMed1992

Effect of surgical manipulation of polytetrafluoroethylene grafts on microstructural properties and healing characteristics.

The effects on graft healing of alterations in the microstructure of polytetrafluoroethylene (PTFE) grafts induced by surgical instruments have not been fully elucidated. This study evaluates changes in the structural and physical properties of PTFE grafts resulting from the intentional application of commonly used surgical instruments and the influence of these changes on cellular ingrowth. The extent of cellular ingrowth into intact (10, 30, and 60 microns unreinforced and 30 microns reinforced [R]) and structurally compromised PTFE grafts (30 reinforced and 60 microns nonreinforced) implanted subcutaneously in Sprague-Dawley (n = 14) rats was evaluated at 7 and 21 days. The thrombogenicity of 10-, 30-, 60-, and 80-microns intact graft segments was determined gravimetrically after suspension in the internal jugular vein of dogs for 90 minutes. Cellular ingrowth consisting of fibroblasts, macrophages, and microvessels was directly related to porosity and was most extensive in 60-microns uncompromised graft segments, being 7-, 17-, and 20-fold greater than was observed in 60- and 30R-microns compromised grafts and undamaged 10-microns grafts, respectively. There was a direct relationship between porosity and thrombogenicity of intact graft segments suspended in the jugular vein. The amount of thrombus adherent to 80-microns graft segments was eightfold greater compared with 10-microns grafts. Manipulation of PTFE with surgical instruments significantly impairs healing and may be a possible etiologic factor in the poor long-term performance of these grafts.

Animals↗
PubMed1992

Emphysematous cystitis: a review of the spectrum of disease.

Emphysematous cystitis is an uncommon condition in which pockets of gas are formed in and around the bladder wall by gas-forming organisms. Persons with diabetes, neurogenic bladder and chronic urinary infection are predisposed to the disease. Severity of illness ranges from an asymptomatic condition to life-threatening cystitis. We present 2 cases of emphysematous cystitis. One case was an incidental finding on evaluation of abdominal discomfort with resolution upon removal of predisposing factors. The other patient presented with an acute abdomen that progressed to severe necrotizing cystitis ultimately requiring cystectomy. The initial involvement of the urologist as a consultant is emphasized. A complete review of the literature describes the incidence, various presentations, associated diseases and organisms, pathogenesis, and available methods for diagnosis and treatment reported for this disease. Successful management depends on early diagnosis with correction of underlying causes, administration of appropriate antibiotics, establishment of adequate bladder drainage and surgical excision of involved tissue when required. Early detection and prompt treatment are encouraged.

Cystitis↗
PubMed1992

Blood loss and transfusion in patients with isolated femur fractures.

A retrospective study of 53 patients with isolated femur fractures was performed to evaluate blood loss and transfusion incidence. Patients with other long bone fractures, abdominal, chest, mediastinal, and vascular injuries were excluded. Twenty-one patients required transfusion during the initial hospitalization averaging 2.5 units PRBCs. Admission hematocrit, preoperative and total EBL were found to be significant variables in determining transfusion. Fracture patterns, classified as high or low energy, were not found to correlate with pre- or intraoperative blood loss, incidence of transfusion, delay to surgery or duration of hospital stay. The estimated blood loss in the study group averaged 1,276 cc, stressing the significance of long bone fractures in trauma patients. Preoperative hemorrhage determined transfusion need in contrast to intraoperative blood loss.

Academic Medical Centers↗
PubMed1992

Updating the management of salvageable splenic injury.

Because of the ready availability of autotransfusers and risk of transfusion-transmitted disease, the authors reexamined the management of splenic trauma. During the past 6 months, 20 adult and pediatric patients were treated for blunt splenic trauma. Nine had "minor" lacerations and were successfully managed nonoperatively. Eleven had ongoing hemorrhage or associated visceral injury necessitating laparotomy. In two, coexistent injuries were life threatening and total splenectomy was performed. The other nine had major splenic trauma that was either an isolated phenomenon or was associated with an injury not jeopardizing survival; eight spleens were salvaged. Mean intra-abdominal blood loss was approximately 1250 mL and, using a "cell saver," an average of approximately 790 mL was reinfused. Six received no other blood transfusion whereas three received 2250 mL homologous blood in addition to 4250 mL via the "cell-saver." With hilar laceration, repair was facilitated by temporarily occluding the splenic pedicle atraumatically, and suturing torn polar branches via the laceration site. In both children and adults with major splenic injury, the authors now recommend early laparotomy with reinfusion of autologous blood. The spleen or a large remnant can usually be salvaged, and homologous blood transfusion with its attendant complication can often be obviated altogether.

Adolescent↗