Robert F. Foran

Management of intestinal fistulas

Abstract A ten year experience of treatment of gastrointestinal fistulas is analyzed. A table of priorities of management is presented with a discussion of supportive therapy and indications for operation. The importance of an optimal, planned, nutritional program is stressed. Adequate nutrition appears to be a decisive factor in survival whether or not the patient requires definitive surgery.

Spontaneous dissection of the internal carotid artery: A nineteen-year clinical experience

PURPOSE This article reviews our experience with internal carotid artery dissection (ICAD), evaluates the usefulness of Duplex scanning in diagnosis, provides current recommendations for treatment, and better defines long-term prognosis. METHODS The records from 1976 to 1995 of 24 patients who had 28 ICAD were reviewed. All diagnoses were confirmed by arteriography. Presenting symptoms, diagnostic tests, clinical management, and outcome were examined. RESULTS Nine patients had visual symptoms or headache, 10 had transient focal neurologic symptoms (TIA), and five had stroke. Five of the 19 who had visual symptoms or TIA had a stroke before the diagnosis of ICAD. Seventeen patients who had 19 ICAD underwent a Duplex scan at the time of presentation. Duplex scan identified 18 arterial abnormalities consistent with ICAD (sensitivity, 95%). Three patients died from stroke during the initial hospitalization. Of the 21 who survived, 12 were treated with anticoagulation therapy, six with aspirin, and three with aspirin and anticoagulation therapy. None of the 21 patients had a subsequent stroke. Six patients subsequently had an operation for residual occlusive disease or aneurysm. The mean duration of follow-up was 9.3 years. Two patients developed contralateral ICAD. During follow-up, 19 arteries were studied with Duplex scan, and seven had no residual evidence of ICAD. CONCLUSIONS Patients who have ICAD often have prodromal symptoms before stroke. If diagnosed early, treatment with anticoagulation may prevent stroke. Duplex scans are accurate for defining carotid abnormalities consistent with ICAD and for indicating the need for arteriography. Patients should undergo a follow-up Duplex scan to identify contralateral ICAD.

Anastomotic false aneurysms of the abdominal aorta and the iliac arteries

Anastomotic false aneurysm (AFA) of the aorta or iliac artery is a potentially lethal complication of prosthetic grafts. To study this complication, the records of 18 patients with 22 noninfected AFAs (15 aortic and seven iliac) were reviewed. Patients with an intact AFA had a pulsatile abdominal mass, abdominal pain, an occluded graft, peripheral emboli, or a femoral anastomotic false aneurysm. All patients with a ruptured AFA were in shock, but 67% (four of six) had symptoms before hemorrhage. For diagnosis, single-plane angiography was 69% accurate (11 of 16), computed tomography was 100% accurate (six of six), and ultrasound was used once and suggested an AFA. Three patients with an AFA less than 5 cm diameter were initially observed; however, all three aneurysms rapidly enlarged and one ruptured. The operative mortality rate was 8% (1 of 12) for patients with an intact aneurysm and 67% (four of six) for patients with a ruptured aneurysm. Treatment was resection of the AFA and replacement with a new graft. Retroperitoneal AFAs often appear years after the initial operation, and life-long follow-up is required for patients with an aortic or iliac graft. All retroperitoneal AFAs should be resected since the outcome of patients with a ruptured AFA is poor.

Aneurysmectomy in the octogenarian: A study of morbidity and quality of survival☆

The records of 52 octogenarians who underwent resection of an abdominal aortic aneurysm were reviewed. Thirty-five elective operations were performed with an operative mortality of 8.6 percent, which was twice that of the group less than 80 years of age. Seventeen emergency operations were performed for rupture with an operative mortality of 58.8 percent. Postoperative follow-up in the elective group found that by 6 months 93 percent of surviving patients had returned to their preoperative status. Survival rates by life table analysis were 67 percent at 1 year, 52 percent at 3 years, and 14 percent at 5 years. In the ruptured group, all patients at risk were alive at 1, 3, and 5 years. We advise elective resection of an abdominal aortic aneurysm in the octogenarian with good functional capacity using the same criteria that we use for younger patients. Most octogenarians can anticipate a prompt return to their usual environment and a meaningful postoperative life-style.

Carotid Endarterectomy in the Elderly

The records of 146 patients 80 years of age or older who underwent 183 carotid endarterectomy operations from 1964 through 1990 were reviewed to determine surgical risk. The indications for operation were asymptomatic patients with carotid stenosis (n=36); ipsilateral transient ischemic attacks (n=46); ipsilateral stroke (n=28); ipsilateral retinal embolus (n=15); nonlateralizing symptoms (n=40); and asymptomatic side in patients with contralateral symptoms (n=18). Postoperatively, three patients (1.6% of operations) had a stroke with a residual deficit and three (1.6%) died. All deaths were from myocardial infarction. For comparison, during the same time period, the combined stroke with residual deficit and death rate for patients less than 80 operated upon for similar indications was 3.5%. Since 80-year-old patients have a life expectancy of at least five years, the authors conclude that elderly patients should be evaluated for carotid endarterectomy using criteria similar to that used for younger patients.

The Diminishing Role of Diagnostic Arteriography in Carotid Artery Disease: Duplex Scanning as Definitive Preoperative Study

In an effort to eliminate the inherent neurologic morbidity associated with arteriographic investigation, we have increasingly relied upon duplex scans of the extracranial carotid arteries prior to endarterectomy. The percentage of patients undergoing carotid endarterectomy without arteriograms has increased from 5% in 1984 to 69% during 1988–1989. Initially, carotid endarterectomy without arteriography was limited to patients with hemispheric symptoms and relative contraindications. Over the course of the study from 1984–1989, indications for operation were similar for patients having carotid endarterectomy on the basis of duplex scan alone or following arteriography. The perioperative outcome for these patients undergoing duplex scan (n=255) and arteriography (n=484) were similar for stroke (2.4% versus 2.7%, p=NS) and death (0% versus 0.4%, p=NS). Stratification of groups by indication did not show any significant differences in outcome. Duplex scans were sufficiently accurate to replace preoperative arteriograms in identifying significant stenoses at the carotid bifurcation, including asymptomatic disease. Lack of information regarding intracranial arterial occlusive disease did not adversely affect perioperative outcome. Carotid arteriography can be used selectively when duplex scans are technically difficult, when physical examination or scans suggest either inflow (arch) disease or diffuse, distal internal carotid plaque, or when cerebral symptoms are not sufficiently explained by duplex findings.

Vascular complications of the intra-aortic balloon pump*

The lower extremity complications of 100 consecutive patients who required the placement of an intra-aortic balloon pump (IABP) during a 3-year period were studied. Indications for the IABP included hypotension during cardiac catheterization (33%) or coronary angioplasty (13%), hemodynamic instability after open heart surgery (35%), unstable angina (5%), and cardiac arrest (14%). The incidence of IABP morbidity was 29%. Complications included ischemia (25%), bleeding (2%), lymph fistula (1%), and femoral neuropathy (1%). Twenty patients required 1 or more surgical interventions for lower extremity vascular complications. The majority of patients who underwent operation (70%) had significant pre-existing arterial occlusive disease. Local femoral artery reconstruction or repair was performed in 18 patients. Two patients had adjunctive bypasses. Continued IABP support was required in four patients after treatment of complications. One patient (1%) had an above-knee amputation. Limb ischemia was treated nonoperatively by removal of the IABP in five patients. Color-flow duplex scans were useful in distinguishing hematomas from pseudoaneurysms as well as for assessing femoral artery flow. We conclude that: (1) limb ischemia remains the primary complication of the IABP; (2) pre-insertion documentation of the severity of existing peripheral arterial disease by noninvasive studies may aid in the management of subsequent acute limb ischemia; (3) femoral artery thrombectomy or endarterectomy is usually sufficient for revascularization; and (4) noninvasive color flow studies are an important diagnostic tool in the nonoperative management of limb complications.

The influence of neutralizing heparin after carotid endarterectomy on postoperative stroke and wound hematoma

The influence of neutralizing or not neutralizing heparin after carotid endarterectomy on postoperative stroke and wound hematoma is unknown. During the past 6 years some of the authors frequently gave protamine sulfate to neutralize heparin, whereas others did not unless a patch was used or wound hemostasis was not readily obtained. To determine the influence of protamine sulfate on stroke and wound hematoma the records of 697 patients having a carotid endarterectomy from January 1984 to September 1989 were reviewed. Protamine sulfate was given to 328 patients, and 369 did not receive protamine sulfate. The incidence of stroke in the two groups was 1.8% (n = 6) and 2.7% (n = 10), respectively, and the difference was not significant (p = 0.6019). Excluding three strokes that could not be related to neutralizing or not neutralizing heparin, the difference remained insignificant (1.5% vs 2.2%, p = 0.7290). The incidence of wound hematoma was 1.8% (n = 6) in patients given protamine sulfate and 6.5% (n = 24) in patients not given protamine sulfate, and this difference was significant (p = 0.0044). The difference remained significant when three hematomas not related to protamine sulfate were excluded (1.2% vs 6.2%, p = 0.0013). In patients not given protamine sulfate draining the wound lessened the incidence of wound hematoma (4.4% vs 8.6%), but this difference was not statistically significant (p = 0.1475). In patients given protamine sulfate the dose of protamine sulfate (15 to 45 mg vs 50 to 75 mg) had no statistically significant effect on the incidence of stroke (0.8% vs 2.0%, p = 0.6530) or wound hematoma (1.6% vs 1.0%, p = 1.000).

Hemosuccus pancreaticus from intraductal rupture of a primary splenic artery aneurysm

Hemosuccus pancreaticus--blood entering the gastrointestinal tract through the pancreatic duct--is a rare and elusive form of gastrointestinal bleeding. The most common cause is a splenic artery pseudoaneurysm caused by acute or chronic inflammation of the pancreas. We report the case of an 86-year-old woman who had recurrent gastrointestinal bleeding from erosion of an aneurysm of the splenic artery into the pancreatic duct. The lack of associated symptoms, equivocal endoscopic findings, and the rarity of this entity resulted in a delay in diagnosis. Nonresective treatment by ligation of the splenic artery proximal and distal to the aneurysm prevented any additional bleeding. Postoperative technetium sulfur colloid scanning demonstrated normal perfusion of the spleen. Only 16 cases of hemosuccus pancreaticus from primary splenic artery disease have previously been reported in the English-language literature (15 primary aneurysms, one medial disruption without an aneurysm). In contrast to cases caused by inflammatory pseudoaneurysms, splenic artery-pancreatic duct fistulas caused by primary aneurysms of the splenic artery should be treated without pancreatic or splenic resection, either with surgery or by embolization. In elderly patients with recurrent gastrointestinal bleeding of obscure source, the differential diagnosis should include the possibility of a ruptured aneurysm communicating with a viscus.

Surgical approach to recurrent carotid stenosis

Abstract The 3.4 percent rate of symptomatic recurrent carotid stenosis after carotid endarterectomy confirms previous reports [7]. Most of the recurrent stenoses occurred in women, and it is postulated that small arteries have less tolerance for myointimal proliferation seen after endarterectomy and that primary patch angioplasty should be considered when the internal carotid artery is less than 3 mm in diameter. When recurrent stenosis of the nonarteriosclerotic type is encountered, patch angioplasty without endarterectomy is the procedure of choice.