Wound complications after infrainguinal bypass. Classification, predisposing factors, and management.

We studied 135 patients during a three-year period to determine the incidence and treatment of wound complications after infrainguinal bypass. The site of distal anastomosis was the popliteal artery in 113 patients, tibial artery in 20 patients, and sequential bypass in two patients. Autogenous vein was used for 79 grafts (59%), polytetrafluoroethylene for 53 grafts (39%), and a composite for three grafts (2%). Perioperative antibiotics were administered to 130 patients (96%). Wound complications were separated into four categories: class 1, erythema or seroma without tissue breakdown; class 2, ischemic necrosis along an incision without infection; class 3, wound breakdown with infection; and class 4, open wound with exposed graft. Ninety incisions (67%) healed without incident. There were 21 class 1 (15%), 17 class 2 (13%), four class 3 (3%), and three class 4 (2%) complications. Serious wound problems were more frequent after bypasses with polytetrafluoroethylene grafts compared with vein grafts. Three prosthetic graft infections resulted in two amputations. Eight other factors were not predictive of wound breakdown. Wound complications after infrainguinal bypass are frequent. Management should be selective, based on the degree of severity.

Late results of peripheral vascular surgery in patients 80 years of age and older.

During a seven-year period, 114 patients 80 years of age and older underwent 119 peripheral arterial procedures. There were 26 elective aortic reconstructions, nine ruptured abdominal aortic aneurysm (AAA) repairs, 33 femoropopliteal bypasses, 13 femorotibial bypasses, 21 femoral embolectomies, and 17 miscellaneous procedures. Early mortality, morbidity, and Goldman cardiac risk factors were determined by chart review. All 48 survivors returned for current noninvasive vascular examination and life-style assessment. Perioperative mortality after elective AAA resection was 4.3%, vs 78% after ruptured AAA. Perioperative mortality after infrainguinal bypass was nil. Five-year survivals after elective aortic and infrainguinal reconstructions were 54% and 30%, respectively. Of 18 patients studied 19 to 68 months after infrainguinal bypass, limb salvage was achieved in 83% and graft patency in 76%. Thirty-one long-term survivors (65%) were living at home. Only seven patients (15%) were confined to a wheelchair or were bedridden, and 28 (58%) were fully ambulatory. Peripheral arterial reconstruction in patients 80 years of age and older can be performed safely with excellent long-term survival and quality of life.

Needle localization and biopsy of nonpalpable lesions of the breast.

Two hundred and three consecutive needle hookwire guided biopsies for nonpalpable lesions of the breast were performed upon 174 patients over a three year period. Patients ranged in age from 25 to 83 years (a mean of 55.4 years). Malignant growths of the breast were found in 44 of 203 specimens taken for biopsy. Sixty-six per cent of malignant lesions were in situ and 34 per cent were invasive carcinoma. The chance of a biopsy containing a malignant lesion was 17.5 per cent if the biopsy was done because of a discrete density on mammography, 22.1 per cent for microcalcifications and 29.6 per cent if both were present. The incidence of Stage I disease in 24 patients undergoing dissection of the axillary lymph node was 79.2 per cent. Specimen roentgenography was done in 165 biopsies. Anesthesia time was increased an average of 5.8 minutes by specimen roentgenography. In 198 instances, the mammographic lesion was present in the specimen taken for biopsy intended to remove it. Minor complications of needle hookwire insertion occurred in two patients. The mortality rate was nil.

Reappraisal of Delorme's procedure for rectal prolapse.

Eighteen patients with second- and third-degree rectal prolapse were treated by simplified Delorme operation during a nine-year period. Operative mortality was nil and significant complications developed in three patients (17 percent). Long-term follow-up (average, 42 months) was established for all 18 patients revealing excellent results in 15 (83 percent). There was only one recurrent prolapse (6 percent) observed during this follow-up period. Technical details of the procedure are described. The simplified Delorme procedure provides acceptable results in the initial surgical management of rectal procidentia.

Early pregnancy on the diaphragm with endometriosis.

The source of hemorrhage in a young woman who required emergency laparotomy for intraabdominal bleeding was found to be a very early primary pregnancy implanted on the undersurface of the right diaphragm, far behind the dome of the liver. Immediately adjacent to this lesion were three tiny foci of endometriosis. This coincidence suggests that the site of nidation may have been a focus of ectopic endometrium rather than peritoneum.