The utility of polyglycolic acid mesh for abdominal access in patients with necrotizing pancreatitis.

BACKGROUND: Necrotizing pancreatitis is a poorly understood process that has been treated by a variety of surgical approaches. Despite advances in operative interventions and critical care, this disease often requires prolonged resource allocation and continues to cause substantial morbidity, with mortality rates ranging from 11% to 40%. We report on our recent series of patients with necrotizing pancreatitis and our experience with the use of an absorbable mesh in a subset of these patients to facilitate their surgical care. STUDY DESIGN: From 1985 to 1994, 40 patients with culture-proved necrotizing pancreatitis underwent operative debridement and drainage. Surgical outcomes were compared among patients who underwent a single debridement and drainage, those requiring multiple procedures, and those having placement of polyglycolic acid mesh. RESULTS: The overall hospital mortality rate was 30%. The mean length of hospital stay was 35 days. The rate of infected pancreatic necrosis was 60%, with a mortality rate of 45% in patients having infected pancreatic tissue at surgery. Patients without infected pancreatic tissue at surgery had a mortality rate of 6% (p = 0.03). Eleven patients requiring multiple operations had placement of absorbable polyglycolic acid mesh. Clinic followup was possible in five of six survivors who underwent mesh closure. Abdominal-wall hernias developed in two patients and were repaired electively, and three patients had spontaneous closure by granulation without abdominal-wall hernias. The average number of operations for debridement and drainage was 2.5 (range, 1-15). Patients with limited pancreatic necrosis required a single operative debridement and drainage, and this was associated with improved outcomes. CONCLUSIONS: Necrotizing pancreatitis remains an important challenge in surgical care. It requires prolonged hospitalization, costly resources, and causes substantial morbidity and mortality. Our patients with infected pancreatic necrosis or clinical deterioration underwent open staged necrosectomy and debridement. Those patients requiring repeat laparotomy often had placement of polyglycolic acid mesh. This provided open drainage of the abdominal cavity and simplified further care by allowing easy abdominal access for repeat drainage procedures, often performed in the intensive care unit. These patients had a high rate of fistula formation, which may be decreased by changes in wound care. Polyglycolic acid mesh is a useful adjunct in the surgical care of selected patients with necrotizing pancreatitis.

Femoral MR angiography versus conventional angiography: preliminary results.

PURPOSE: To develop a bilateral femoral magnetic resonance (MR) angiographic examination that would include the aortic bifurcation to the ankle. MATERIALS AND METHODS: Thirty-seven patients underwent conventional angiography and the bilateral femoral MR angiographic examination. Two-dimensional time-of-flight angiography was used for all studies. RESULTS: The femoral MR angiogram could have replaced the conventional angiogram in 57% of patients (21 of 37). In 43% of patients (16 of 37), the femoral MR angiogram could not have replaced the conventional angiogram. Reasons for diagnostic failure with femoral MR angiography included artifact from vascular clips (n = 8) or prosthetic joints (n = 3), overlooked distal aortic stenosis (n = 1), and suboptimal definition of vessels (usually trifurcation vessels) owing to various causes (n = 8). Seven of the patients in this group had bypass grafts. CONCLUSION: Some of the current limitations of femoral MR angiography could be avoided by supplemental duplex sonography around prostheses and vascular clips. The other limitations will require advances in MR imaging techniques.

Aortoenteric fistulas.

During an 11-year period ending in December 1991, 36 patients with aortoenteric fistulas were assessed and treated. Twenty-five patients (69%) had previously undergone aortic reconstruction with Dacron grafts, and 11 (31%) had spontaneous aortoenteric fistulas. Of the 25 patients with secondary fistulas, 14 (56%) had undergone aortic aneurysmal rupture or multiple aortic vascular reconstructions. Preoperative diagnosis was established in only 13 (36%) of 36 patients. Remote bypass preceding removal of the infected arterial prosthesis had the least morbidity and mortality. Three primary fistulas were found in unusual locations: aortocolonic, aortobronchial, and aortoesophageal. The patient with the aortoesophageal fistulas was the fifth survivor described in the literature. The overall mortality was 56%. A positive preoperative blood culture predicted a poor outcome. There were four amputations, there due to infection of the extra-anatomical bypass. Prompt directed assessment to ensure appropriately staged operative intervention should improve survival.

Intraarterial streptokinase infusion for acute popliteal and tibial artery occlusion.

Eight consecutive patients with acute thrombotic or embolic occlusion of the popliteal or tibial artery were treated with low-dose intraarterial streptokinase followed by arterial reconstructive surgery where appropriate. Three patients had acute thrombosis of a popliteal aneurysm with limb-threatening ischemia. All three were relieved of their acute ischemia by streptokinase infusion accompanied by lysis of clots in the popliteal artery outflow tract. Each patient then underwent elective popliteal aneurysm bypass. Four patients had acute embolic popliteal or tibial artery occlusion. Each was relieved of ischemic symptoms. One required surgery to remove residual clot. One patient with thrombosis of the tibioperoneal trunk did not have a decrease in symptoms with streptokinase infusion, but did experience sufficient outflow tract thrombolysis to permit construction of a tibial bypass with resultant restoration of normal circulation. Low-dose intraarterial streptokinase may be the treatment of choice for selected patients who present with thrombosis of a popliteal aneurysm with tibial vessel involvement or with embolic popliteal or tibial artery occlusion.

Extended profundaplasty. Indications and techniques with results of 46 procedures.

We performed extended profundaplasty 46 times in 36 patients. Twelve procedures were performed for ischemic ulcers, 23 for ischemic rest pain and 10 for short-distance claudication. Fourteen procedures were performed independently, 21 to provide outflow for proximal bypass grafts, and 11 were combined with distal bypass grafts. Four of the 46 procedures failed; the rest have been successful for limb salvage or relief of symptoms at a mean follow-up of 15 months. Technical points emphasized are autogenous patch closure of the entire endarterectomy site and careful attention to end-point detail. The results demonstrate that this procedure provides durable limb revascularization.

Surgical treatment of chronic visceral ischemia.

Our experience with the operative repair for chronic visceral ischemia in eight patients, including two patients without visceral ischemic symptoms, is described. We prefer revascularization of as many vessels as possible and have used a small diameter Dacron bifurcation graft directed cephalad from the infrarenal aorta to the superior mesenteric artery and hepatic or splenic artery in four patients. One patient died postoperatively of an arrhythmia. Three patients died of unrelated causes 7 to 36 months after surgery. Four patients are alive 8 to 48 months after surgery. All patients were relieved of the intestinal ischemic symptoms by surgery.

Endoscopic retrograde cholangiopancreatography in the diagnosis and management of nonalcoholic pancreatitis.

Twenty-eight consecutive patients with idiopathic pancreatitis were studied. Endoscopic retrograde cholangiopancreatography was diagnostic in 21 of 28, while an operation was diagnostic in four of the remaining seven patients. Fifteen of 25 patients had operable disease of the gallbladder, common bile duct, ampulla of Vater or pancreatic duct. Of ten patients who had an operation on the pancreas or biliary tract, or both, for painful attacks of pancreatitis, none had a recurrence in a seven month to three year follow-up study. Two patients had reconstruction of the pancreatic duct for chronic painless steatorrhea, one of whom had marked clinical improvement. Ten of 25 patients had normal biliary tracts with normal or minimally abnormal pancreatic ducts and were treated medically. Visualization of biliary and pancreatic ducts should be attempted by endoscopic retrograde cholangiopancreatography in patients with pancreatitis of unknown cause. Operable lesions were found in 15 of 25 patients, and the postoperative results were excellent.

Lower extremity amputation for ischemia.

Three hundred-twenty-four amputations of the lower extremity for ischemia at the University of Oregon Health Sciences Center over the past ten years are presented. Striking differences between the first and second five-year periods are noted in level of amputation. The primary healing rate of all patients in the two periods was similar. Diabetics tended to have more distal amputations but primary healing was lower than that of nondiabetics.

The role of arteriography in abdominal aortic aneurysm.

The results of arteriography in the management of 100 consecutive patients with abdominal aortic aneurysms are presented. Arteriographic information had substantial influence upon management decisions and performance of surgery in 75 per cent of cases. We found the preoperative knowledge of the precise vascular pathology or anatomic variants not only permitted a more rational recommendation for or against surgery but aided in the selection of the most suitable surgical procedure.

Comparison of heparin and streptokinase in the treatment of venous thrombosis.

Heparin or streptokinase was administered in a prospective randomized fashion to 50 patients with phlebographically confirmed venous thrombosis of the extremities of 14 days or less duration. A total of 49 patients completed the investigative protocol with 26 receiving heparin and 23 receiving streptokinase. All patients were evaluated with sequential phlebograms. Complete thrombolysis with restoration of venous valve function occurred in one of 26 patients receiving heparin and in six of 23 patients receiving streptokinase. Fifty per cent of the patients treated with streptokinase with a total duration of symptoms of three days or less achieved complete lysis. The total incidence of therapeutic complications was similar in the two groups, but was more severe in the streptokinase treated patients.

Multimodality therapy in the treatment of regionally inoperable melanomas and sarcomas.

Nine patients with regionally inoperable malignant melanoma or soft tissue sarcoma were treated with combinations of intra-arterial chemotherapy, immunotherapy and operation or irradiation or both. Three of the heretofore untreatable patients with melanoma remain clinically free of detectable metastases at three years, three and one-half years and one and one-half years from their recurrence. One nodular melanoma remains well controlled two years after diagnosis, while an additional patient is free of disease several months after therapy. Two of the patients with melanoma died within a year of the onset of the recurrence but maintained the affected limb in useful condition until the time of their death. Two of the three patients with sarcoma remain free of disease at ten and four years. One patient who was known to have distant metastatic disease at the onset of the treatment currently is hospitalized for further therapy for tumor in the para-aortic lymph nodes.

The diagnosis and treatment of Raynaud's phenomenon.

Twenty-five patients with Raynaud's phenomenon, including 20 with associated diseases and five with primary Raynaud's disease, were evaluated with sequential determinations of digital temperature recovery time after cold exposure and magnification hand arteriography before and after cold exposure and before and after intra-arterial reserpine. A variety of immunologic screening tests were performed, and the clinical response to oral guanethidine of phenoxybenzamine was determined. Temperature recovery time was prolonged in all but two patients with Raynaud's phenomenon before treatment. Arteriography revealed luminal obstruction of variable degree in all but two patients with Raynaud's phenomenon but not in those with Raynaud's disease. Radiographic vasospasm was noted in all patients. Patients with Raynaud's symptoms had a markedly greater vasospastic response to cold exposure than did three control patients without Raynaud's symptoms. Arteriography 48 hours after intra-arterial reserpine repeat revealed decreased vasospasm and a decreased vasospastic response to cold in most patients. A variety of serum protein and serologic aberrations were detected, with only eight patients being free of immunologic abnormalities, Nineteen patients were treated with guanethidine alone, three with guanethidine-phenoxybenzamine combination, and one with phenoxybenzamine alone. Good or excellent clinical results were noted in 19 of the 23 patients treated, with an average follow-up to date of 12 months.

Axillary-axillary artery bypass for the correction of subclavian artery occlusive disease.

Numerous procedures have been proposed for the correction of symptomatic subclavian artery occlusive disease, none of which have been uniformly accepted by vascular surgeons. During the past 21 months we have successfully treated six patients with symptomatic subclavian artery occlusive disease by the construction of an axillary-axillary artery bypass. There were three complications in this small series, a wound hematoma, a case of median nerve parasthesias, and a late graft thrombosis, possibly caused by external pressure on the graft. These complications have not caused any serious morbidity. All patients have been followed to the present time, all have experienced symptomatic improvement and none has developed any symptoms of donor arm ischemia. Axillary-axillary artery bypass is currently our procedure of choice for the correction of symptomatic subclavian artery occlusive disease because of its effectiveness, absence of serious morbidity and ease of performance.