Thomas H Gouge, M.D.

Percutaneous treatment of thoracic duct injuries
Marcon, Francesca; Irani, Katayun; Aquino, Theresa; Saunders, John K; Gouge, Thomas H; Melis, Marcovalerio
2011 Sep;25(9):2844-2848, Surgical endoscopy
BACKGROUND: Major thoracic or neck surgery or penetrating trauma can cause injury to the thoracic duct and development of a chylothorax. Chylothorax results in metabolic and immunologic disorders that can be life threatening, with a mortality rate reaching 50%. The management of chyle leaks is dependent on the etiology and daily output. Interventions are used to treat only leaks unresponsive to medical management or those with an output exceeding 1,000 ml/day. METHODS: This study reviewed the existing literature on the percutaneous management of chyle leaks. The authors evaluated five case series and three case reports inclusive of 90 patients in which percutaneous treatment for chylothorax was attempted between 1998 and 2004. RESULTS: For 71 patients, percutaneous treatment was technically successful, and chylothorax resolved in 49 of the patients (69%). Percutaneous treatment of chylothorax was associated with a 2% morbidity rate and no mortality. For 19 patients whose percutaneous approach failed, either surgical ligation or pleurodesis was performed. CONCLUSIONS: The percutaneous management of chyle leak is feasible, with low morbidity and mortality rates and a high rate of effectiveness. This approach should be considered before more invasive procedures
— id: 136938, year: 2011, vol: 25, page: 2844, stat: Journal Article,

Safety of hepatic resections in obese veterans
Saunders J.K.; Rosman A.S.; Neihaus D.; Gouge T.H.; Melis M.
2011 ;13:60-60, HPB : the official journal of the International Hepato Pancreato Biliary Association
Introduction: We aimed to determine the effects of body mass index (BMI) on outcomes after liver resection performed at the Veteran Administration. Methods: We queried the VASQIP database for liver resections (2005-2008), and grouped the patients into fi ve categories: normal weight (NW, BMI 18.5-24.9), overweight (OW, BMI 25-29.9) Class 1 (OB1, BMI 30-34.9), Class 2 (OB2, BMI 35-39.9), and Class 3 obesity (OB3, BMI >= 40). Differences in risk factors and perioperative complications across groups were analyzed. Results: Of 403 patients who underwent hepatectomy, 106 (26.3%) were NW, 161 (40.0%) OW, 94 (23.3%) OB1, 31 (7.7%) OB2, and 11 (2.7%) OB3. The BMI groups were similar in patient gender, age, diagnosis (90.3% malignancy), ASA class, rates of alcohol abuse, ascites, esophageal varices, and neoadjuvant treatment. Higher BMI was associated with increased rates of diabetes (18% vs. 27% vs. 36% vs. 39% vs. 45%, p 0.04) and lower incidence of smokers (53% vs. 35% vs. 30% vs. 16% vs. 9%, p 0.0001). There were no differences in type of resection performed, operative time, work RVU. OB3 received more blood transfusions (OB3 4.3 +/- 2.7 vs. NW 1.1 +/- 0.2, p 0.02). There were no differences across BMI groups in overall and specifi c morbidity, as well in length of stay. Nevertheless, compared to the other groups OB3 had a higher 30-day mortality (27% vs. 6%, 0.05). Multivariate analyses confi rmed BMI > 40 as an independent predictor of post-operative mortality. Conclusion: Obesity did not increase post-operative complications in veterans after liver resection. Mortality was higher in patients with BMI > 40
— id: 127251, year: 2011, vol: 13, page: 60, stat: Journal Article,

Impact of mandatory resident work hour limitations on medical students' interest in surgery
Miller, George; Bamboat, Zubin M; Allen, Frederick; Biernacki, Peter; Hopkins, Mary Ann; Gouge, Thomas H; Riles, Thomas S
2004 Nov;199(4):615-619, Journal of the American College of Surgeons
BACKGROUND: The number of US medical students applying for general surgery residency has been declining. Recent studies have shown that the issue of 'controllable lifestyle' has become a critical factor in medical students' decision-making process. We postulate that widespread implementation of resident work hour limitations would bolster medical students' interest in pursuing surgical careers. STUDY DESIGN: Students from New York University School of Medicine were surveyed about their attitudes toward work hour limitations and its effect on their interest in pursuing a surgical residency. One hundred thirty-two students participated. RESULTS: Nearly 95% of respondents believed that work hour limitations were a positive change and, if all other factors were equal, they would choose a training program that used work hour limitations over one that did not. The most common reasons cited in favor of limits were improvements in resident lifestyle (42%) and patient safety (34%). Fifty-three percent of respondents indicated that presence of work hour limitations alone would increase their interest in considering a surgical residency and only 2% of medical students indicated that it would lessen their interest in surgery. Not surprisingly, intellectual interest in a specialty was the most important factor in choosing a residency for 86% of students. Nevertheless, work hour limitations were designated a higher priority than future salary by 55% of medical students. CONCLUSIONS: The presence of work hour limitations has a positive impact on medical students' interest in surgery. Widespread implementation of work hour limitations may bolster the number of applications for surgical residency
— id: 46084, year: 2004, vol: 199, page: 615, stat: Journal Article,

Attitudes of applicants for surgical residency toward work hour limitations
Miller, George; Bamboat, Zubin M; Allen, Frederick; Hopkins, Mary Ann; Gouge, Thomas H; Riles, Thomas S; Nalbandian, Matthew M
2004 Sep;188(2):131-135, American journal of surgery
BACKGROUND: There is an ongoing debate regarding the merits of resident work-hour limitations. We postulated that this issue would be a factor in the decision-making process of applicants to surgical residency. METHODS: Candidates for surgical residency at a university-based program completed an anonymous survey during their visit. Data was analyzed by analysis of variance and the chi-square test. RESULTS: Most candidates viewed work-hour limitations as being favorable to their future training. Nevertheless, work-hour limitations ultimately were not a critical factor in the decision-making process compared with issues such as quality of training and program reputation. Candidates ranked 'reading in surgery' the most likely way they would spend the leisure time afforded by work-hour limitations. CONCLUSIONS: Most applicants for surgical residency consider work hour-limitations as being favorable to their training and view the extra free time as an opportunity for furthering their education. However, other issues take precedence when choosing a residency
— id: 46008, year: 2004, vol: 188, page: 131, stat: Journal Article,

Decreasing length of stay after pancreatoduodenectomy
Brooks AD; Marcus SG; Gradek C; Newman E; Shamamian P; Gouge TH; Pachter HL; Eng K
2000 Jul;135(7):823-830, Archives of Surgery (Chicago)
HYPOTHESIS: Decreased length of stay (LOS) after pancreatoduodenectomy is due to multiple factors, including a lower complication rate and more efficient perioperative care for all patients, with and without complications. DESIGN: A retrospective review, validation cohort. SETTING: A single university hospital referral center. PATIENTS: A consecutive sample of patients undergoing pancreatoduodenectomy from January 9, 1986, to December 21, 1992 (group 1 [n = 104]) and from February 16, 1993, to November 9, 1998 (group 2 [n = 111]). INTERVENTION: Mann-Whitney test and linear [correction of logistic] regression analysis applied to clinical variables and LOS. MAIN OUTCOME MEASURES: Difference in median LOS between early and late groups and identification of factors predictive of decreased LOS. RESULTS: Total LOS decreased between the 2 groups (26 days [range, 13-117 days] vs 15 days [range, 5-61 days]; P<.001), with a decrease in preoperative (4 days [range, 0-28 days] vs 2 days [range, 0-36 days]; P<.001) and postoperative (19 days [range, 11-95 days] vs 12 days [range, 4-58 days]; P<.001) LOS (data given for group 1 vs group 2). Major complications decreased from 49% in group 1 to 25% in group 2 (P<.001). Postoperative LOS decreased for patients with (25 days [range, 15-95 days] vs 20 days [range, 8-58 days]; P = .05) and without (15 days [range, 11-47 days] vs 11 days [range, 4-55 days]; P<.001) major complications (data given for group 1 vs group 2). Multivariate analysis identified age (P = .01), pancreatic fistula (P<.001), delayed gastric emptying (P<.001), biliary complications (P<.001), operative time (P<.005), extra-abdominal infection (P<.005), use of a percutaneous stent (P = .04), and year of operation (P<.001) as independent predictors of total LOS. CONCLUSION: A reduction in complications in combination with factors leading to a streamlining of perioperative care has contributed to the decreased LOS after pancreatoduodenectomy
— id: 9076, year: 2000, vol: 135, page: 823, stat: Journal Article,

Predicting comorbidity in patients with pancreatic fistulae following pancreaticoduodenectomy
Karpoff, HM; Sivamurthy, N; Oh, C; Gouge, TH; Pachter, HL; Eng, K; Shamamian, P; Marcus, SG
1998 APR 15 ;114(4):A1398-A1398, Gastroenterology
— id: 53477, year: 1998, vol: 114, page: A1398, stat: Journal Article,

Gangrene of Meckel's diverticulum secondary to axial torsion: a rare complication
Malhotra S; Roth DA; Gouge TH; Hofstetter SR; Sidhu G; Newman E
1998 Aug;93(8):1373-1375, American journal of gastroenterology
A Meckel's diverticulum may result in a number of complications including hemorrhage, obstruction, and inflammation. We report a case of a gangrenous Meckel's diverticulum secondary to axial torsion, which has been reported only four times in adults and once in children in the past 28 years
— id: 12084, year: 1998, vol: 93, page: 1373, stat: Journal Article,

Endoscopic biliary drainage before pancreaticoduodenectomy for periampullary malignancies
Marcus SG; Dobryansky M; Shamamian P; Cohen H; Gouge TH; Pachter HL; Eng K
1998 Mar;26(2):125-129, Journal of clinical gastroenterology
Despite decreased operative mortality, pancreaticoduodenectomy (PD) remains a formidable operation with substantial morbidity. We have evaluated the influence of preoperative endoscopic biliary drainage (EBD) on morbidity after PD for malignant biliary obstruction by retrospectively reviewing the medical records of 182 patients undergoing PD between April 1985 and August 1996. Of 52 study patients with malignant obstructive jaundice, 22 underwent preoperative EBD, and 30 were not drained. Eighty-three patients were excluded for bilirubin levels less than 5 mg/dl, 43 had other biliary drainage, and 4 had jaundice with benign pathology. Preoperative, intraoperative, and postoperative factors were compared. The two groups were well matched for clinical presentation and operative characteristics except for lower preoperative values of liver chemistries in patients undergoing EBD. Length of postoperative hospitalization for patients undergoing EBD was 13.5 days, compared with 19 days for patients who were not drained (p = 0.02). Patients who were not drained tended to have more overall complications (p = 0.054). Multivariate analysis revealed time to regular diet (p < 0.0001) and no preoperative drainage (p = 0.04) to be independent factors significantly increasing the length of hospitalization. Endoscopic biliary drainage before PD significantly reduced the length of postoperative hospitalization and was associated with less postoperative morbidity. Further studies, including cost analysis, are warranted
— id: 7673, year: 1998, vol: 26, page: 125, stat: Journal Article,

A combined laparoscopic and endoscopic approach to acute primary gastric volvulus
Newman RM; Newman E; Kogan Z; Stien D; Falkenstien D; Gouge TH
1997 Jun;7(3):177-181, Journal of laparoendoscopic & advanced surgical techniques. Pt. A
We describe the combined use of laparoscopic and endoscopic techniques in a case of acute primary gastric volvulus. Once the diagnosis is confirmed with a water-soluble upper gastrointestinal series, prompt intervention is required. With an atraumatic bowel grasper the stomach is re-oriented with the greater curvature in its normal anatomic position. Two transabdominal wall sutures are placed along the greater curvature to fix it to anterior abdominal wall. Upper endoscopy is then performed. Once confident that the gastric mucosa is viable, a 20F 'pull-type' gastrostomy tube is placed endoscopically, guided by the external illumination and probing by the laparoscope. The gastrostomy tube now acts as an anterior anchor for the stomach allowing repositioning of the gastropexy sutures if necessary. Endoscopy confirms the placement of a broad, properly aligned gastropexy. Classically, gastric volvulus has been treated by laparotomy. Both endoscopic and laparoscopic techniques have been individually reported in the treatment of acute and chronic gastric volvulus, however, each has as its limitations. By combining the procedures we were able to better assess both the intra-abdominal and the intraluminal status of the stomach and its position before, during, and after fixation to the anterior abdominal wall. The postoperative stay seen with the combined technique was less than has been reported in patients treated by open surgery or by either the endoscopic or laparoscopic methods alone. The combined laparoscopic and endoscopic approach to acute gastric volvulus provides the benefit of a minimally invasive approach, to a better anterior gastropexy. This procedure should be considered when confronted with patients with acute primary, gastric volvulus
— id: 12170, year: 1997, vol: 7, page: 177, stat: Journal Article,

Factitious gastrointestinal bleeding: a case of autophlebotomy and ingestion
Rose MI; Dicker MA; Gouge TH
1996 Jul;91(7):1457-1459, American journal of gastroenterology
— id: 56888, year: 1996, vol: 91, page: 1457, stat: Journal Article,

Fundoplication and gastrostomy in familial dysautonomia
Axelrod FB; Gouge TH; Ginsburg HB; Bangaru BS; Hazzi C
1991 Mar;118(3):388-394, Journal of pediatrics
Fundoplication with gastrostomy has become a frequent treatment for patients with familial dysautonomia, so we evaluated the use of both procedures in 65 patients. Although patients differed widely in presenting signs and age, from 5 weeks to 40 years, gastroesophageal reflux was documented in 95% of patients by cineradiography or pH monitoring. Panendoscopy was a useful adjunct. Preoperative symptoms of gastroesophageal reflux included vomiting, respiratory infections, and exaggerated autonomic dysfunction. Severe oropharyngeal incoordination frequently coexisted and resulted in misdirected swallows with aspiration, dependence on gavage feedings, or poor weight gain and dehydration. Follow-up after surgical correction ranged from 3 months to 11 years; 55 patients (85%) were available for a 1-year postoperative assessment. We had no instances of surgical death. The long-term mortality rate was 14%, primarily related to severe preexisting respiratory disease. Beyond the first postoperative year, 30 patients had pneumonia attributed to continued aspiration, exacerbation of preexisting lung disease, or recurrence of gastroesophageal reflux. Of 11 patients who vomited postoperatively, six had recurrence of reflux. Recurrence of gastroesophageal reflux was documented in eight patients (12%), and we revised the fundoplication in three patients. The number of patients with cyclic crises was reduced from 18 to 7; retching replaced overt vomiting in all but two of these seven patients, neither of whom had recurrence of reflux. Because oropharyngeal incoordination was prominent, concomitant use of gastrostomy and an antireflux procedure was especially effective in the treatment of younger patients with familial dysautonomia, before the development of severe respiratory disease. Despite the development of severe morning nausea in 15 patients, the combination procedure resulted in significantly improved nutritional status, decreased vomiting, and decreased respiratory problems. Appropriate use of gastrostomy feedings also contributed to success of the operation. The generally good outcome of fundoplication with gastrostomy confirms the benefit of this procedure in familial dysautonomia
— id: 14114, year: 1991, vol: 118, page: 388, stat: Journal Article,

Blast injury to the thoracic esophagus
Guth AA; Gouge TH; Depan HJ
1991 May;51(5):837-839, Annals of thoracic surgery
Blast injury causing pneumatic disruption of the esophagus is a rare and potentially lethal injury. The mortality and morbidity rate are high unless the injury is promptly recognized and treated. Our experience with a midesophageal perforation resulting from a blast injury emphasizes the importance of awareness of this condition and of the chest radiograph in making an early diagnosis
— id: 14027, year: 1991, vol: 51, page: 837, stat: Journal Article,

Angiosarcoma at the site of a Dacron vascular prosthesis: a case report and literature review
Weiss WM; Riles TS; Gouge TH; Mizrachi HH
1991 Jul;14(1):87-91, Journal of vascular surgery
Four of 32 reported sarcomas related to the aorta have arisen around previously placed aortic vascular prostheses suggesting that the graft may have been an etiologic factor. Our recent experience with such an angiosarcoma arising around a Dacron aortic graft prompted a review of the lesion to identify risk factors, diagnostic approaches, and treatment options. The diagnosis of these sarcomas is seldom made before operation. Animal studies have implicated plastic polymers including Dacron as carcinogenic materials capable of inducing sarcoma in 7% to 50% of exposures. Because of the rarity of these tumors and the thousands of vascular implants used over the past 30 years, it is unlikely that this degree of risk can be extrapolated to humans. However, a tumor should be included in the differential diagnosis of any mass or thromboembolic event associated with a vascular prosthesis
— id: 13985, year: 1991, vol: 14, page: 87, stat: Journal Article,

Experience with the Grillo pleural wrap procedure in 18 patients with perforation of the thoracic esophagus [see comments]
Gouge TH; Depan HJ; Spencer FC
1989 May;209(5):612-617, Annals of surgery
Perforation of the thoracic esophagus may be fatal unless diagnosed promptly and treated with an effective operation. The wide mortality range in different reports reflects the importance of these two factors. This range spans from as low as 11%, if operation is within 24 hours, to greater than 50% after two to three days. The high mortality with delayed treatment is principally due to inability to surgically close the perforation. Eighteen patients (aged from 31 to 78 years) were treated four hours to 14 days after thoracic esophageal perforation (less than 24 hours: 7 patients; 24 to 72 hours: 7 patients; greater than 72 hours: 4 patients). In 14 patients the perforation was sutured, after which the suture line was buttressed with a circumferential wrap of parietal pleura, originally described by Grillo. Underlying esophageal pathology was corrected and wide mediastinal drainage was instituted. All 14 patients recovered and were discharged from the hospital after a median stay of 20 days. Two patients had minor leaks at the suture line that soon closed. Four patients had perforations too extensive to close. Of these, one was resected, the Urschel procedure was used in two, and the Abbott T-tube drainage was used in one. Three of the four patients died. It was quite significant that the pleural wrap was equally effective with both early (6 patients) and delayed perforations (8 patients). These data indicate that the pleural wrap should be used routinely. Extensive perforations that cannot be closed should probably be treated by resection and drainage, followed by esophageal reconstruction at a later time
— id: 10642, year: 1989, vol: 209, page: 612, stat: Journal Article,

Neutropenic typhlitis simulating carcinoma of the cecum
Musher DR; Amorosi EL; Gouge T; Megibow AJ; Press RA
1989 Sep-Oct;35(5):449-451, Gastrointestinal endoscopy
— id: 10496, year: 1989, vol: 35, page: 449, stat: Journal Article,

Cutaneous bile fistula treated with ERCP-placed large diameter stent
Musher DR; Gouge T
1989 Nov;55(11):653-655, American surgeon
Endoscopic retrograde cholangiopancreatography (ERCP) with placement of endobiliary prostheses has become an important means of treatment for obstructing lesions of the biliary tract especially since the advent of therapeutic endoscopes capable of placing large diameter stents. A case is presented in which a patient with a cutaneous bile fistula responded overnight to endoscopic placement of a large diameter endobiliary prosthesis
— id: 42294, year: 1989, vol: 55, page: 653, stat: Journal Article,

Esophageal transection and paraesophagogastric devascularization for bleeding esophageal varices
Gouge, T H; Ranson, J H
1986 Jan;151(1):47-54, American journal of surgery
The Sugiura procedure is feasible in an unselected, high risk population of alcoholic patients with cirrhosis who have bleeding esophageal varices and poor hepatic reserve. The Sugiura procedure controlled variceal bleeding in every patient with active bleeding and prevented early rebleeding, however, the operation is tedious, time-consuming, and has a high complication rate related to the thoracic approach. The rate of anastomotic leakage of 8.6 percent (4.8 percent in elective cases) is not as high as might be anticipated, but led to death in every case. The long-term outlook for these patients is poor, and the rebleeding rate of 37 percent in our lowest risk patients is disappointingly high. Similar results can be achieved with simpler procedures
— id: 92870, year: 1986, vol: 151, page: 47, stat: Journal Article,

TREATMENT OF BLEEDING ESOPHAGEAL-VARICES BY THE SUGIURA PROCEDURE - RESULTS OF EMERGENCY OPERATION
GOUGE, TH
1986 SEP ;62(7):754-758, Bulletin of the New York Academy of Medicine
— id: 41553, year: 1986, vol: 62, page: 754, stat: Journal Article,

Hepatic resection for metastatic colon and rectal cancer. An evaluation of preoperative and postoperative factors
Coppa, G F; Eng, K; Ranson, J H; Gouge, T H; Localio, S A
1985 Aug;202(2):203-208, Annals of surgery
Hepatic resection for metastatic colorectal cancer has been reported in over 700 patients. However, approximately 5000 patients each year are candidates for surgical excision. Since 1972, 25 patients have undergone hepatic resection for colorectal metastases at New York University. Potentially curable synchronous lesions were detected by preoperative liver chemistries and operative palpation. Patients were screened for metachronous lesions by serial liver chemistries and carcinoembryonic antigen (CEA) determinations; when clinical findings or laboratory findings were either positive or equivocal, then scanning techniques were used. Most patients had solitary lesions (20). Thirteen of 25 lesions were synchronous; 12 were metachronous. Anatomic lobectomy was performed in 13 patients (6 extended resections); and wedge resection was performed in 12. The operative mortality rate was four per cent; the 2-year survival rate, 65%; the 5-year survival rate, 25%. Hypertonic dextrose solutions were administered during and after operation. Post-operative albumin requirements ranged from 200 to 300 grams/day. Coagulation factors II, V, VII, and fibrinogen decreased after surgery to 30 to 50% of their preoperative levels. Subsequent elevation of these factors correlated with increased bile production and improvement in liver chemistries 10 to 14 days after operation. At present, hepatic resection for colorectal metastases provides the only potential method of salvage, offering a 20 to 25% long-term survival rate
— id: 92872, year: 1985, vol: 202, page: 203, stat: Journal Article,

Multifocal granular cell tumors of the gastrointestinal tract
Fried KS; Arden JL; Gouge TH; Balthazar EJ
1984 Oct;79(10):751-755, American journal of gastroenterology
Granular cell tumors infrequently appear in the gastrointestinal tract. Lesions have been reported in all segments from the esophagus to the rectum, but no previous reports have identified simultaneous lesions in various segments. We describe a patient with granular cell tumors of the esophagus, stomach, appendix, and cecum. Our case emphasizes the need to evaluate the entire gastrointestinal tract when a single lesion is identified. The radiographic approach and pathological characteristics are discussed. Therapeutic alternatives are presented
— id: 43901, year: 1984, vol: 79, page: 751, stat: Journal Article,

Parenteral and oral antibiotics in elective colon and rectal surgery. A prospective, randomized trial
Coppa, G F; Eng, K; Gouge, T H; Ranson, J H; Localio, S A
1983 Jan;145(1):62-65, American journal of surgery
Our evaluation consisted of a prospective, randomized clinical trial in a homogenous group of 241 patients undergoing elective colon and rectal resections. A significant decrease in wound infection was found in the patients who received intravenous cefoxitin in conjunction with standard bowel preparation. The infection rate correlated with the type of resection; rectal resections had the highest rate in each study group, but parenteral prophylaxis produced a significantly lower wound infection rate. E. coli and Staph. aureus were the most common bacterial isolates in both groups. B. fragilis was recovered in only two Group A patients, which most likely reflects the exceedingly low recovery rate of anaerobic bacteria in our laboratory. Urinary cultures were positive in a large number of patients and reflect the standard use of Foley catheterization in all patients who undergo resection of the colon or rectum. These data indicate that perioperative prophylactic administration of cefoxitin reduces the wound sepsis rate when combined with oral antibiotics and mechanical bowel preparation in patients undergoing resection of the colon or rectum
— id: 92880, year: 1983, vol: 145, page: 62, stat: Journal Article,

Management of diverticulitis of the ascending colon. 10 years' experience
Gouge, T H; Coppa, G F; Eng, K; Ranson, J H; Localio, S A
1983 Mar;145(3):387-391, American journal of surgery
Diverticulitis of the ascending colon is an uncommon disease which mimics appendicitis. The correct diagnosis is rarely made, but can be suggested by the patterns of signs and symptoms and confirmed by barium contrast study. Diverticulitis of the ascending colon should be treated by the same plan as diverticulitis of the left colon. If the diagnosis is established, nonoperative management is indicated initially. Operation is indicated when the diagnosis is in doubt, when perforation has occurred, or when the patient does not respond to nonoperative treatment. At operation, ascending colon diverticulitis can be recognized as an inflammatory mass involving the wall and mesentery of the colon. The inflammatory mass is best treated by resection with primary anastomosis of the ileum to the ascending or transverse colon in an area removed from the site of infection
— id: 92879, year: 1983, vol: 145, page: 387, stat: Journal Article,

Air embolism: a lethal but preventable complication of subclavian vein catheterization
Coppa, G F; Gouge, T H; Hofstetter, S R
1981 Mar-Apr;5(2):166-168, Journal of parenteral & enteral nutrition. JPEN
Air embolism (AE) is a rare but lethal complication of subclavian vein catheterization (SVC). Although treatable, if recognized promptly, attention should be directed towards prevention. SVC has been used at New York University Medical Center since 1969 for parenteral nutrition; its safety and complications have been recognized and reported. Since 1976, 14 patients with AE from SVC have been observed. Thirteen occurred as a sudden catastrophic event associated with disconnection of the catheter; all had significant morbidity; 4 (29%) died; 9 (65%) had associated profound neurologic deficit from which 5 recovered completely. Five others had cardiorespiratory morbidity but also recovered. In 1 surviving patient air was aspirated from the right atrium with immediate improvement. Survivors had evidence of pulmonary AE characterized by hypoxia. AE is a syndrome of respiratory distress, hypotension, and neurologic deficit of sudden onset. Immediate treatment is aspiration through the catheter in the left lateral steep Trendelenburg position. Review of our experience with AE suggests that lack of integrity of the connection between the catheter and the intravenous tubing was the responsible mechanism in the majority of case (93%). Secure fixation of these connections is vital for the prevention of AE
— id: 77796, year: 1981, vol: 5, page: 166, stat: Journal Article,

The radiation-injured bowel
Localio SA; Pachter HL; Gouge TH
1979 ;11:181-205, Surgery annual
Radiation disease of the intestine is usually iatrogenic and frequently unavoidable. The disease, its treatment, and the disability produced are formidable. There is hope that means may be found to increase the resistance of the intestine to radiation damage. Radiation enteropathy is an insidious, progressive disease that is seen with increasing frequency. Serious disabilities may develop after years of gestation. Those patients who require surgery are treated by control of sepsis, correction of metabolic abnormalities, and reversal of protein/calorie malnutrition prior to definitive surgery. The treatment of choice is resection with anastomosis, but recurrences may occur many years later in intestine grossly normal at the time of surgery
— id: 60006, year: 1979, vol: 11, page: 181, stat: Journal Article,

Effects of suture selection and local and distant sepsis on colonic wound healing
Berman IR; Gouge TH; Goodyear J; Iliescu H
1978 ;29:18-19, Surgical forum
— id: 11457, year: 1978, vol: 29, page: 18, stat: Journal Article,

Abdominosacral resection for carcinoma of the midrectum: ten years experience
Localio, S A; Eng, K; Gouge, T H; Ranson, J H
1978 Oct;188(4):475-480, Annals of surgery
Abdominosacral resection allows curative resection of midrectal cancer with excellent preservation of sphincter function. In the last ten years 427 patients underwent resection for rectal carcinoma at University Hospital by one surgeon. (SAL) The operation, selected by preoperative sigmoidoscopic measurement, was anterior resection (AR) in 239, abdominosacral resection (ASR) in 100, and abdominoperineal resection (APR) in 88. Operative mortality was 1.7% for AR, 2% for ASR and 2.3% for APR. All patients were completely continent of stool and flatus after AR and ASR. Follow-up is complete in 194 of 195 patients treated five to ten years ago. Five year survival for curative resection (no distant metastases) was 67.3% after AR (66/98), 58.3% after ASR (21/36), and 50% after APR (15/30). For patients without tumor in lymph nodes, survival rates were 78.3% for AR, 64.3% for ASR and 63.2% for APR. With involvement of regional nodes, survival fell to 41.4% for AR, 37.5% for ASR and 27.3% for APR. For lesions at 5-8.5 cm, five year survival was 61.1% for ASR and 58.3% for APR. No statistical difference in survival time was noted when patients were matched for age, sex, level of lesion and extent of spread. Pelvic recurrences were detected in 16.7% after ASR, 15.3% after AR and 33.3% after APR. All of the pelvic recurrences after ASR and the majority of those after AR and APR occurred in patients with tumor invasion of perirectal fat. These data strongly support the applicability of ASR as an important advance in the treatment of midrectal cancer. Although technically demanding, ASR has permitted preservation of anal continence without sacrifice of long-term cure in approximately 50% of patients who would otherwise have required APR
— id: 92893, year: 1978, vol: 188, page: 475, stat: Journal Article,

Perforated diverticula of the jejunum and lleum
Roses DF; Gouge TH; Scher KS; Ranson JH
1976 Nov;132(5):649-652, American journal of surgery
Over a ten year period, four patients with inflammation or perforation of non-Meckelian, small intestinal diverticula were treated on the surgical services of Bellevue Hospital. This entity remains uncommon but may be increasing in incidence. The patients presented with a short history of severe abdominal pain, usually accompanied by nausea and vomiting. Each patient also gave a longer preceding history of less well defined abdominal symptoms. The pathogenesis of the small intestinal diverticula is uncertain but may be related to disturbed muscular peristalsis in the small bowel analogous to the changes implicated in esophageal and colonic diverticular disease. The diverticulum may be difficult to demonstrate at operation, and careful exploration for this possibility should be carried out at the time of operation for peritonitis of obscure origin. Segmental resection and end-to-end anastomosis is the treatment of choice
— id: 25114, year: 1976, vol: 132, page: 649, stat: Journal Article,

The effect of normothermic anoxic arrest and ventricular fibrillation on the coronary blood flow distribution of the pig
Engelman, R M; Adler, S; Gouge, T H; Chandra, R; Boyd, A D; Baumann, F G
1975 Jun;69(6):858-869, Journal of thoracic & cardiovascular surgery
Normothermic anoxic arrest of 15 and 30 minutes, repeated for up to a total of 90 minutes of anoxia was employed in 24 pigs. The purpose was to determine the effect of varying the duration of anoxia on coronary blood flow, coronary vascular resistance, and the distribution of coronary flow to the free wall of the ventricle. Five minutes of reperfusion at pressures of 50 and 100 mm. Hg with the ventricle fibrillating, was employed between each anoxic interval. Results were compared to control studies performed during ventricular fibrillation without anoxic arrest in 12 pigs. Prolonging the anoxic interval to 30 minutes served to create a maldistribution of coronary flow away from the left ventricular endocardium and to reduce the reactive hypermic response to anoxia. Increasing the perfusion pressure to 100mm. Hg accentuated these changes. Both light and electron microscopy of sections demonstrated edema and early myocardial necrosis in the subendocardial layer of the left ventricle subjected to repeated 30 minute intervals of anoxia at a high perfusion pressure. We postulate that repeated anoxic insults with inadequate repayment of oxygen debt results in subendocardial edema, a decrease in perfusion, increasing necrosis, and further edema. A myocardial infarction must result if this vicious cycle cannot be interrupted
— id: 106543, year: 1975, vol: 69, page: 858, stat: Journal Article,

DELAYED PRESENTATION OF DIAPHRAGMATIC INJURY
Gouge, T
1975 ;75(3):388-389, New York state journal of medicine
— id: 28496, year: 1975, vol: 75, page: 388, stat: Journal Article,

Villous tumors of the duodenum
Kutin ND; Ranson JH; Gouge TH; Localio SA
1975 Feb;181(2):164-168, Annals of surgery
Villous tumors of the duodenum are rare, but treatment may be problematic because of their association with invasive adenocarcinoma. Two cases of villous tumor of the duodenum are described and 39 other reported cases are reviewed. Presenting symptoms were bleeding 27%; obstruction 24%; jaundice 22% and vague dyspepsia 20%. Diagnosis may be made by radiographic barium contrast evaluation of the duodenum, especially with the addition of air contrast hypotonic studies and by fibro-optic endoscopy. Twenty-seven per cent of villous tumors of the duodenum are associated with adenocarcinoma. Invasive tumor is more common in patients over 50 years old (35%), in tumors of the third and fourth portions of the duodenum (44%) and in tumors over 4 cm in diameter (30%). Local excision is the treatment of choice for benign lesions. Pancreatico-duodenectomy is recommended for tumors which include invasive carcinoma in patients without distal metastases
— id: 22209, year: 1975, vol: 181, page: 164, stat: Journal Article,

The effect of diuretics on renal hemodynamics during cardiopulmonary bypass
Engelman, R M; Gouge, T H; Smith, S J; Stahl, W M; Gombos, E A; Boyd, A D
1974 Mar;16(3):268-276, Journal of surgical research
— id: 78184, year: 1974, vol: 16, page: 268, stat: Journal Article,

Effect of normothermic anoxic arrest on coronary blood flow distribution of pigs
Engelman, R M; Spencer, F C; Adler, S; Gouge, T H; Chandra, R; Boyd, A D
1974 ;25(0):176-179, Surgical forum
— id: 107034, year: 1974, vol: 25, page: 176, stat: Journal Article,

RENAL HEMODYNAMICS DURING CARDIOPULMONARY BYPASS
Gouge, TH; Smith, SJ; Boyd, AD; Engelman, RM
1974 ;50(3):401-401, Bulletin of the New York Academy of Medicine
— id: 28460, year: 1974, vol: 50, page: 401, stat: Journal Article,

CLOSED CHEST LEFT ATRIAL-FEMORAL BYPASS, A SUPERIOR MODE OF THERAPY FOR CARDIOGENIC-SHOCK - EXPERIMENTAL AND CLINICAL STUDIES
Lipson, D; Engelman, RM; Boyd, AD; Gouge, TH; Spencer, FC; Glassman, E; Ackerman, B
1974 ;50(3):408-408, Bulletin of the New York Academy of Medicine
— id: 28462, year: 1974, vol: 50, page: 408, stat: Journal Article,

Mediastinitis following open-heart surgery. Review of two years' experience
Engelman RM; Williams CD; Gouge TH; Chase RM; Falk EA; Boyd AD; Reed GE
1973 Nov;107(5):772-778, Archives of Surgery (Chicago)
— id: 18901, year: 1973, vol: 107, page: 772, stat: Journal Article,

Renal and hepatic dysfunction following cardiopulmonary bypass
Engelman, R M; Brenner, W I; Gouge, T H; Reed, G E; Boyd, A D; Isom, O W
1973 ;Spec No:676-682, Journal of cardiovascular surgery
— id: 107037, year: 1973, vol: Spec No, page: 676, stat: Journal Article,

Closed-chest left atrial-femoral bypass for cardiogenic shock: experimental and clinical studies
Lipson, D E; Glassman, E; Engelman, R M; Boyd, A D; Gouge, T H; Ackerman, B; Spencer, F C
1973 ;24:180-181, Surgical forum
— id: 107038, year: 1973, vol: 24, page: 180, stat: Journal Article,