Calvin B. Ernst

Vascular surgery in the United States: Workforce issues: Report of the society for vascular surgery and the international society for cardiovascular surgery, North American chapter, committee on workforce issues

The Committee on Workforce Issues of the Society for Vascular Surgery (SVS) and the North American Chapter, International Society for Cardiovascular Surgery (NA-ISCVS) generated data on the numbers and trends of operations performed and workforce requirements to provide surgical care of patients with vascular disease. Data for analysis were obtained from The National Center for Health Statistics-National Hospital Discharge Survey and questionnaires sent to 2732 vascular surgeons. The data showed that SVS/NA-ISCVS and regional vascular society (RVS) surgeons performed 51% of 583,000 vascular procedures undertaken in the United States in 1992. This represents a 24% increase over the 41% reported in 1985 by similarly defined surgeons. Analysis of 1992 index cases documented that SVS/NA-ISCVS and RVS surgeons accounted for 80% of 31,000 aortoiliofemoral bypasses, 68% of 46,000 aortic aneurysmectomies, 64% of 91,000 carotid endarterectomies, and 72% of 98,000 angioaccess procedures. The mean numbers of vascular operations performed in 1992 by SVS/NA-ISCVS and RVS surgeons were 144 and 100, respectively. These procedures represented 64% and 39% of the total surgical caseload of SVS/NA-ISCVS and RVS surgeons, respectively. American Board of Surgery (ABS)-certified vascular surgeons performed a mean of 171 vascular operations in 1992. Other surgeons, including ABS-certified general surgeons, appear to be performing fewer vascular operations. The latter fact and the increasing incidence of vascular disease in an expanding elderly population supports a continued need for vascular surgery specialists. Evolving technology and new health care delivery systems, however, may lessen the need for surgical care of these patients. Continued assessments of workforce activity will allow better definition of changing vascular surgery needs.

Secondary aortoenteric fistula: A 20 year experience☆

During a 20 year period at the Johns Hopkins Medical Institutions, 17 patients were operated on for secondary aortoenteric fistula. The interval from initial operation to the onset of symptoms varied greatly and averaged 2.8 years. Symptoms included not only gastrointestinal bleeding but also sepsis and abdominal or back pain. Associated advanced cardiovascular disease was common. Helpful preoperative diagnostic studies included esophagogastroduodenoscopy, aortography, barium contrast gastrointestinal series and groin sinography. However, a high index of suspicion was the most important element of diagnosis. Overall operative mortality was high (47 percent). All six patients with a graft left in the retroperitoneum had an unsatisfactory result (four instances of recurrent aortoenteric fistula). Successful repair was accomplished only in those patients undergoing graft excision and axillofemoral bypass.

The spectrum of emetogenic injury to the esophagus and stomach

Abstract The classic examples of postemetic injury to the esophagus and stomach, laceration of the mucosa with hemorrhage (the Mallory-Weiss syndrome) and rupture of the lower part of the esophagus (Boerhaaves syndrome), are being recognized and treated with increased frequency. The findings in nine patients with postemetic lesions are reviewed, demonstrating a spectrum of injury. Of special interest are two patients with intramural “dissections” of the stomach and esophagus not previously described. Pitfalls in the diagnosis and management of postemetic injuries are discussed. Reliance on “classic” clinical history and physical findings may be misleading. The Mallory-Weiss syndrome should be considered in any patient with hematemesis, with or without pain. Abdominal or chest pain after emesis, with or without hematemesis, should be a warning of possible rupture or significant intramural injury to the stomach or esophagus.

Use of Doppler pressure measurements in predicting success in amputation of the leg

Fifty-five patients underwent amputation of the leg. Fifty-eight percent of the amputations were above-knee and 32 percent below-knee. Preoperative Doppler ankle blood pressure measurements and ankle/brachial ratios were compared and correlated with wound healing in patients with below-knee amputation. Statistical analysis documented that such measurements were significant in predicting wound healing. If blood pressure greater than 55 mm Hg at the knee, greater than 70 mm Hg at the incision site or greater than 70 mm Hg at the ankle or an ankle/brachial ratio of at least 0.3 is documented, satisfactory healing will follow amputation.

Agenesis of the gallbladder

Abstract All case reports of agenesis of the gallbladder in our review of the literature have been categorized as to proved, probable, possible (insufficient evidence), or questionable on the basis of the amount and type of evidence available to support each claim. Thirty-seven authors have reported fifty-six patients in the English literature with proved agenesis of the gallbladder; agenesis was confirmed at operation in thirteen of these patients and at autopsy in forty-three. Three new cases of agenesis of the gallbladder are reported, two of which were confirmed at operation and one at autopsy.

Use of arteriography in the diagnosis of occult gastrointestinal and traumatic intra-abdominal hemorrhage☆☆☆

Abstract Selective visceral arteriography has proved to be a reliable diagnostic adjunct in evaluating selected cases of gastrointestinal hemorrhage or blunt abdominal trauma. Its use is advocated in gastrointestinal hemorrhage which cannot be localized by conventional diagnostic methods. Experimental work suggests that active bleeding at the rate of at least 0.6 ml. per minute may be identified by the appearance of intraluminal contrast medium during late phases of the arteriogram. Such observations were made clinically in two patients. In the absence of active bleeding other arteriographic features characteristic of aneurysm or tumor may demonstrate the responsible lesion. After blunt abdominal trauma, arteriography has proved useful in evaluating the presence or absence of intraabdominal visceral injury in five patients. Hepatic laceration and hematoma, thrombosis of the renal artery, and two cases of splenic tear were demonstrated by arteriography in four patients. The clinical evidence against the need for operative intervention was substantiated by a visceral arteriogram revealing no abnormalities in an eighth patient.

Management of vascular soft tissue neoplasms using transcatheter embolization and surgical excision

Preoperative embolization of highly vascular soft tissue tumors was performed in four patients. Selective catheterization of branch vessels supplying the tumors successfully avoided inadvertent embolization of adjacent normal tissue. Operative blood loss was significantly less than anticipated, permitting an easier, more precise, and quicker operation. Two of the lesions were benign intramuscular hemangiomas; one was a fibrosarcoma, and one, a malignant schwannoma. Three tumors were resected completely. A small portion of one hemangioma could not be removed. All patients were free of recurrence during follow-up periods of 6 to 14 months.

Surgical treatment of acquired and congenital arteriovenous fistulae

More than 230 years have passed since William Hunter’s classic description of chronic arteriovenous fistula (AVF) of the extremity. Although Hunterian quadrilateral ligation has been replaced by contemporary vascular reconstruction, the principles and justification for operation remain the same.