Joaquin Sariego

Major long-term complications in 1,422 permanent venous access devices

A retrospective review was undertaken of 1,422 permanent venous access devices (PVADs) implanted from 1989 to 1991 at Hahnemann University Hospital. This included 730 single-lumen Hickman catheters, 368 double-lumen Hickman catheters, 307 single-lumen Portacath infusion ports, and 17 double-lumen Portacath infusion ports. Indications for placement were as follows: antibiotics in 28%; chemotherapy in 51%; hyperalimentation in 4%; intravenous fluids in 4%; hemodialysis in 3%; and undocumented indications in 10%. There were 60 PVADs removed and/or replaced prior to the completion of intended therapy (4% overall). Indications for removal were catheter infection in 1% of cases and catheter malfunction in 3% of cases. The percentage of Portacath infusion ports removed was significantly greater than the percentage of Hickman catheters that were removed (p < 0.001). However, there was no significant relationship between catheter infection or the malfunction rate, and the number of lumens, initial indication for placement, or number of catheters placed. Life-threatening complications associated with PVAD insertion occurred in fewer than 1% of cases. The insertion of PVADs is a safe and efficient mode of long-term venous access.

Operative ultrasound guidance for various surgical procedures

Although percutaneous ultrasound-guided technique is currently a common practice, the use of ultrasound for the purpose of guidance during surgery has not been widely practiced. Over a period of 10 years, we performed operative ultrasonography in 2,314 operations. In 321 of these operations, operative ultrasound guidance was performed for direct assistance of various surgical procedures, particularly during operations on the brain and spinal cord, liver, pancreas, and kidney. Procedures guided by operative ultrasound were classified into the following categories: intraoperative needle placement for fluid aspiration (n = 38), agent injection (n = 14), catheter introduction (n = 27), biopsy (n = 57), surgical tissue dissection for incision (n = 48), resection (n = 82) of organs, and extraction (n = 55) of stones or foreign bodies. Operative ultrasound guidance facilitates various surgical procedures and is considered a useful modality for reducing operative complications, shortening operating time, performing otherwise impossible procedures, and, at times, developing new surgical operations.

Thrombolytic therapy of synthetic graftocclusions before vascular reconstructive procedures

The objective of this study was to evaluate the impact of thrombolysis of synthetic grafts before urgent vascular reconstruction. In 29 patients, 41 thrombosed synthetic grafts that underwent intraarterial thrombolysis were studied. The cases were divided into three groups: group I--complete thrombolysis followed by reconstruction; group II--complete thrombolysis alone; and group III--incomplete lysis requiring reconstruction or sympathectomy. Follow-up ranged from 1 to 556 days (mean: 149 days). Kaplan-Meier analysis was used to determine patency and limb salvage rates. One-year patency and limb salvage rates were 53% and 95%, 34% and 67%, and 38% and 48%, respectively, for groups I, II, and III. Eighteen complications occurred in 16 of the 41 (39%) episodes. One patient died of intracranial hemorrhage. The best results were achieved when complete lysis was followed by appropriate reconstruction. Patency was equally poor in complete thrombolysis alone and reconstructions required by incomplete thrombolysis. Limb salvage was better after complete thrombolysis, regardless of the appropriate reconstruction.

Colonoscopically guided tube decompression in Ogilvie's syndrome

Ogilvies syndrome (pseudo-obstruction of the colon) may result in gangrene and perforation of the colon if not effectively treated. Colonoscopic decompression and endoscopically guided rectal tube placement were employed to treat five patients with this syndrome who had failed medical therapy. All patients tolerated the procedure well and required no further treatment.

University-based postresidency training programs in surgical oncology

The issue of postresidency training in surgical oncology engenders much debate, particularly as it impacts on general surgery training. With the goal of enhancing instruction in surgical oncology in the future, a survey was conducted to assess the role of surgical oncology programs and educational activities within university-based surgery training programs. The results of the study demonstrate an increased emphasis on surgical oncology training over the past five years. The findings also indicate that education activity in surgical oncology in all departments of surgery has increased greatly, as demonstrated by an increased number of specific teaching rounds and conferences. The impact of this increased awareness on the future of surgical oncology training is discussed.

Cancer knowledge and misconceptions among college undergraduates: A pilot study

A study of cancer knowledge and misconceptions among college undergraduates was undertaken with the goal of obtaining information that could be used to direct the establishment of future, problem-oriented cancer education programs. General knowledge about cancer, as well as specific knowledge about colon cancer, was found to be lacking. The former was significantly related to gender, while the latter was influenced by a family history of cancer. Knowledge about breast cancer was more complete, although, again, gender significantly impacted upon accuracy. Breast self-examination and surgical options for treating breast cancer were specific areas in which knowledge was poor.

Intraoperative Balloon Dilation as an Adjunct to Bypass Surgery

Intraoperative balloon dilation (with or without laser assistance) was performed on 30 lesions in 20 patients in whom proposed bypasses distal to the tibioperoneal trunk were revised to more proximal bypasses (above- or below-knee femoropopliteal) following successful dilation. Only 3 patients overall required subsequent amputation—at one month, nine months, and one year postoperatively, respectively. There were 3 deaths from unrelated causes; all had patent grafts at time of death. Two patients were lost to follow-up. This experience reinforces the beneficial adjunctive role of intraoperative balloon dilation in patients who require long bypasses, allowing less extensive reconstructive procedures to be performed and consequently yielding better long-term results than surgery alone.

Failed Vascular Reconstructive Procedures with Profoundly Ischemic Limbs—Treated by Lumbar Sympathectomy

The purpose of this study was to assess the impact of lumbar sympathectomy on limb loss in patients with prior reconstructive vascular surgery. One hundred and one patients underwent 118 lumbar sympathectomies. The 118 limbs were grouped presympathectomy into: rest pain (41), tissue breakdown (55), and gangrene (22). All vascular procedures were femoral-popliteal or femoral-distal bypass. No change in segmental Doppler pressures occurred after lumbar sympathectomy. Sixty-nine of 118 (58%) limbs underwent amputation following sympathectomy, a mean of two (range: one to twenty-two) months following the procedure. Of those limbs with an amputation (69/118), 14/69 (20%) had one reconstructive procedure, 41/69 (60%) had two reconstructive procedures, and 14/69 (20%) had three reconstructive procedures. Of those without an amputation (49/118 limbs), 27 had one vascular recon structive procedure, 9 had two reconstructive procedures, and 3 had three reconstructive procedures before sympathectomy. (continued on next page) Of the patients with diabetes (47), 44/47 (94%) underwent amputation, 35/44 (80%) with below-the-knee and 9/44 (20%) with above-the-knee amputation. Limb loss (69 limbs) by category was: rest pain, 21/41 (51%); nonhealing ulcers, 38/55 (69%); and gangrene, 10/12 (83%). Lumbar sympathectomy may be a useful procedure in very selected patients; diabetic patients who undergo reconstructive vascular surgery are not good candidates. Segmental Doppler pressures do not help predict successful or improved outcome following lumbar sympathectomy.