A ten year experience with cadaver kidney preservation using cryoprecipitated plasma.

Between August 1967 and January 1977, 699 cadaver kidneys were preserved and transplanted in our hospital after continuous perfusion with cryoprecipitated plasma. Overall graft survival of primary transplants was 55 +/- 2 per cent at one year and 41 +/- 2 per cent at four years. The results with ninety-six second transplants were similar. The number of HLA antigens shared and the duration of preservation did not influence graft survival. Patient survival among 426 cadaver graft recipients since September 1972, when lower dose immunosuppression was started, was 91 +/- 1 per cent at one year and 84 +/- 2 per cent at four years, significantly better than survival before then. Survival of fifty-two recipients of cadaver retransplants since September 1972 was 86 +/- 5 per cent at one year and 86 +/- 5 per cent at four years, which was better than before. The incidence of posttransplantation dialysis was 30 per cent and did not correlate with the length of preservation. Primary wound infections, primary ureteral extravasation, and vascular complications each occurred with an incidence of 1.1 per cent or less in patients treated with lower dose immunosuppression. Only four kidneys were lost because of complications, and in no instance was the need for transplant nephrectomy directly related to the method of preservation. Perfusion preservation with cryoprecipitated plasma gives excellent results compared with alternative methods.     

Advances in management of splenic injuries.

Because there is no such thing as "minor splenic injury", the diagnosis of splenic rupture is a major problem after abdominal trauma. Since it is our policy to explore all penetrating abdominal injuries, the problem of early recognition arises in patients with blunt trauma. When abdominal evaluation is difficult because of associated injuries, we increasingly use peritoneal dialysis. This has been particularly helpful in patients with head injury or drug intoxication and has also contributed to earlier operation in patients with signs of hypovolemia but minimal abdominal findings. Angiography has been useful in doubtful cases. Review of our experience in the last five years with splenectomy (298 cases) has revealed complications, particularly thromboembolic, that have changed our management of these patients. The incidence of clinical pulmonary embolism was 4 per cent in patients having splenectomy for trauma as contrasted with 0.5 per cent in patients having laparotomy for trauma without splenectomy. Postoperative platelet evaluations in patients after splenectomy for trauma revealed thrombocytosis. Detailed follow-up platelet studies showed a peak thrombocytosis at about two weeks, averaging 976,000/mm3. In contrast, similar studies in other patients having laparotomy for trauma showed counts of about 200,000/mm3. Because of the high incidence of thromboembolic complications, a low-dose heparin regimen was initiated. There was a 30 per cent incidence of infection postoperatively.     

Septic phlebitis: A neglected disease

A review of 100 patients with peripheral septic phlebitis revealed that 54 per cent of the cases were due to intravenous catheters and 46 per cent were secondary to drug abuse. Eighty per cent of the involved veins were in the arm or neck. Pain was the most common symptom (83 per cent), with erythema and edema the most common physical signs (63 per cent). Eighty per cent of the causative organisms were gram-positive bacteria, usually Staphylococcus aureus (41 per cent) or Group A streptococcus (20 per cent). Complications were more common if septic phlebitis was due to intravenous therapy than drug abuse.No deaths were directly attributed to septic phlebitis. However, hospital stay after development of septic phlebitis was 14 days with a 56 per cent complication rate. The initial treatment of septic phlebitis should include prompt removal of the intravenous device, antibiotics, heat, and elevation. Because serious complications occur in a significant number of patients, operative excision of the involved vein should be performed if clinical deterioration occurs or if septicemia persists after 24 hours despite conservative therapy.     

Complications of continent ileostomy.

Immediate postoperative complications occurred in 15 per cent of 39 patients undergoing continent ileostomy, and late complications developed in 46 per cent of these patients. Age over 40 years, obesity, and Crohn's disease were related to the morbidity rate, but corticosteroid therapy was not a factor. Results of primary operations were superior to those of secondary continent ileostomies. With careful selection of patients and attention to technical detail, success in 90 per cent of initial continent ileostomy operations is a realistic goal.     

Ultimate salvage for the patient with limb-threatening ischemia. Realistic goals and surgical considerations

Ultimate salvage for the patient with a severely ischemic lower limb should be the preservation of bipedal gait. Arterial reconstructions which will sustain the limb by restoring circulation will accomplish this objective if the limb is functional. However, major amputations of the leg performed for ischemia are increasing yearly despite the proliferation of “salvage” bypass procedures. Evaluation of large experiences in revascularizations performed to popliteal or distal arteries for limb salvage reveal: (1) mortality 4 per cent; (2) early graft failure 20 to 35 per cent, late failure (2 years) 30 to 50 per cent; (3) amputation despite patent graft 7 to 10 per cent; and (4) factual palliation (2 years) less than 50 per cent. To these must be added the number of patients who required an above-knee amputation after their revascularization attempt failed, in whom a primary below-knee amputation would have healed.Primary healing has been achieved at the below-knee level in 80 per cent of such patients, most of whom are successfully returned to ambulatory status. Since the rehabilitation time is doubled and the attainment of independent bipedal gait halved with an above-knee amputation, the importance of the knee joint for ambulation cannot be overemphasized. In view of these observations, the wisdom of proceeding with a tenuous arterial reconstruction for treatment of patients with advanced limb ischemia is questioned. Primary below-knee amputations should be used more often in this setting. Appropriate therapy should not interfere with the dysvascular patient attaining the ultimate goal: social and economic independence through the preservation of bipedal gait.     

Traumatic injuries of the diaphragm. Diaphragmatic hernia

Trauma to the diaphragm may be direct or indirect, and herniation may be obscured by concomitant injuries and may remain occult for many years.The early physical signs and symptoms are meager before the abdominal organs have penetrated deeply into the thorax. The progress of injury can be divided into three phases: (1) initial, (2) latent, and (3) obstructive.Most traumatic hernias occur on the left side because of the diminished buffering force on the undersurface of the left hemidiaphragm. Roentgenograms are most often misinterpreted as indicating eventration of the diaphragm, gastric dilatation, or lesions in the lower lung fields or pleura. A dilated stomach in the left pleural cavity may simulate a pneumothorax. Diaphragmatic injury should always be considered in conjunction with trauma to the liver, kidneys, and spleen. Intestinal obstruction may occur with few significant abdominal findings, when most of the involved viscera are in the thorax. The thoracic approach to surgery provides excellent exposure. The herniated viscera which may be adherent to the lung or pericardium can be released conveniently, there is easy access to the diaphragmatic rent, and lacerations near the heart and esophagus can be repaired without fear of further injury. Extensions or separate abdominal incisions may be necessary to manage concomitant injuries, especially in the initial phase.Wounds of the diaphragm are not likely to heal spontaneously; often the omentum or other viscera plug the laceration, thereby preventing acute herniation. However, this same mechanism separates the muscle edges, preventing their union. Traumatic ruptures of the diaphragm are twelve times more common on the left side due to the protection afforded by the liver. Diaphragmatic tears are most common in the dome and the posterior half which are the areas of embryonic weakness. When strangulation of bowel occurs in the thorax, approximately 90 per cent of the cases are due to traumatic hernia of the diaphragm, and when strangulation occurs, the mortality varies from 25 to 66 per cent.     

The risk and accuracy of pancreatic biopsy.

Pancreatic biopsy in 171 patients produced complications in 4.7 per cent and death in 1.7 per cent. The biopsy diagnosis was confirmed in 86 per cent but was falsely negative in 14 per cent of pancreatic cancers. Frozen sections were interpreted correctly in all cases. Wedge biopsy resulted in fewer complications and fewer false-negative results than needle biopsy and is preferable except for periampullary lesions in which transduodenal needle biopsy is best. When the biopsy incision transected a pancreatic duct, suture ligation and drainage avoided complications. Open transduodenal biopsy of periampullary lesions was reliable, but the duodenotomy closure leaked in 10 per cent of the cases. Pancreatic biopsy with confirmation of malignancy should precede pancreaticoduodenectomy in most cases of suspected pancreatic cancer.     

Infection in vascular prostheses. Clinical manifestations and surgical management

The clinical manifestations and results of management in twenty-seven patients treated for infected vascular prostheses are reviewed. The mortality of 37 per cent and a loss of limb rate of 37 per cent are testimony to the serious nature of the problem. The over-all incidence of infection in our series of prosthetic grafts is 2.5 per cent; however, grafts inserted between 1966 and 1973 have an infection rate of 1.5 per cent as compared to that of grafts inserted prior to 1966 when the infection rate was 4.1 per cent. The most likely explanation for this lowered rate of infection was a corresponding change in prophylactic antibiotic management.     

Renosplenic shunt for control of esophageal variceal hemorrhage.

The left renal vein was used to perform a renosplenic (38 patients) or an adrenosplenic (5 patients) shunt in forty-three patients with esophageal variceal hemorrhage. All patients were successfully decompressed without recurrence of variceal bleeding in the postoperative period. One shunt thrombosed six months postoperatively and one kidney was removed because of venous hypertension and spontaneous rupture two days postoperatively. Overall mortality was 16 per cent, including a 22 per cent mortality in the emergency group.     

Compound fractures of the pelvis

A retrospective study of sixteen patients with pelvic fractures compounded through the perineum, rectum, or vagina showed a mortality of 50 per cent. The cause of death in seven of the eight patients was sepsis and multisystem failure. The initial surgical management of these patients must include complete diversion of the fecal stream so that pelvic and systemic sepsis may be prevented.     

Epidemiology of trauma deaths

The records of all 437 persons who died from trauma in San Francisco in 1977 were examined. Sixty-five percent of the sample (285 were younger than 50 years, and 119 were between ages 21 and 30. Gunshot wounds (140 or 32 percent) and falls (122 or 28 percent) were the most common causes of injury. Fifty-three percent of the sample were dead at the scene of injury before transport could be accomplished, 7.5 percent died in the emergency room, and 39.5 percent died in the hospital. Fifty-five percent of the 359 patients who died within the first 2 days died from brain injury, while 78 percent of the 55 late deaths were due to sepsis and multiple organ failure. In 10 cases (2 percent), death was due to delayed transport or to errors in diagnosis and treatment and was deemed preventable. The key areas in which advances are necessary in order to reduce the number of trauma deaths are prevention of trauma, more rapid and skilled transport of injured victims, better early management of primary brain injuries, and more effective treatment of the late complications of sepsis and multiple organ failure.     

Surgical treatment of chronic pancreatitis

The results of surgery for chronic pancreatitis in fifty-seven patients treated between 1958 and 1972 were reviewed. The findings have been used to outline a surgical strategy for the management of this disease.Operations on the biliary tract gave disappointing results. Biliary disease must be treated when present, but this will not always lessen chronic pancreatic pain.The surgical treatment of pseudocysts by internal drainage was uncomplicated in the short run, but almost half the patients continued to have pain months or years later.Direct operations on the pancreas are most successful in chronic pancreatitis. Sphincterotomy, splanchnicectomy, gastric operations, and caudal pancreaticojejunostomy are no longer recommended. When the pancreatic duct is dilated, longitudinal pancreaticojejunostomy (Puestow operation) will effect improvement in 80 to 90 per cent of patients. Pancreatitis localized to the tail of the gland is optimally treated by hemipancreatectomy. Subtotal (95 per cent) pancreatectomy is reserved for diffuse pancreatitis when the pancreatic duct is small or when previous longitudinal pancreaticojejunostomy is unsuccessful.     

Complications of nonoperative extraction of retained common duct stones.

A morbidity of 5 per cent and no mortality occurred in 612 reported patients undergoing nonoperative extraction of retained common duct stones. Three patients with complications required reoperation, but morbidity and mortality with this new procedure of percutaneous stone removal is significantcantly less than that with operative reexploration of the common duct. The use of small caliber T tubes results in a greater rate of failure and entails more complications. A T tube of no less than number 14 French caliber should be used routinely [2]. Penrose drains should be placed separately from the T tube, and the T tube should be brought out through a lateral stab wound.     

Postsympathectomy neuralgia. Amelioration with diphenylhydantoin and carbamazepine

Fifty-six consecutive patients who subsequently underwent ninety-six lumbar sympathectomies were studied prospectively with regard to the development of postoperative pain. Pain after operation was observed in thirty-four extremities by twenty-five of the patients (35 per cent). It began abruptly an average of twelve days after operation and was often accentuated nocturnally. The pain was almost always described as a deep, dull ache and persisted two to three weeks before spontaneously remitting. Postsympathectomy pain of such severity that parenteral narcotics afforded no relief developed in two of these fifty-six patients and in nine additional patients. Treatment with carbamazepine produced dramatic reduction in the intensity of pain in seven of these nine patients within twenty-four hours after the institution of therapy. Two patients were given intravenous diphenylhydantoin and both experienced immediate relief of pain. The mechanisms of the syndrome and of the action of these drugs are uncertain.     

Thermal injury: defects in immune response induction.

The immunocompetence of leukocyte subpopulations from mice which had received a 10% scald burn has been examined following injury. Leukocytes from the burned animals were reduced 80% in their ability to generate de novo antibody-forming cells in vitro. When leukocytes from the injured animals were supplied with the immunologically active factors produced by normal A and T leukocytes, their immunocompetence was restored. These experiments indicate that: (i) Thermal injury directly reduces the immune activity of leukocytes; (ii) the thermal-induced leukocyte injury is time dependent; and (iii) the leukocyte subpopulation affected is not the antibody-forming B cell.     

Unusual problems of abdominal aortic aneurysms

Complications other than rupture occurred in 12 per cent of 254 patients operated on for an infrarenal abdominal aortic aneurysm. The unusual problems encountered included aortocaval fistula, inflammatory aneurysm, aortoenteric fistula, aortic thrombosis, peripheral embolization, and retropsoas rupture. The clinical manifestations and management of these lesions are discussed.     

Morbidity and mortality in hepatic trauma: A 5 year study

The records of 443 cases of liver trauma operated on at San Francisco General Hospital from 1976 to 1981 were reviewed. Forty-two percent of the injuries were due to blunt trauma, 32 percent to stabbings, and 26 percent to gunshot wounds. Seventy-two percent of the patients were treated by simple repair and only 8 percent of patients had to undergo major resection. Infections and pulmonary problems were the most common complications, and the overall morbidity was 38 percent. Associated injuries occurred in 84 percent of patients. Our overall mortality was 9 percent; mortality for blunt trauma was 14 percent, for gunshot wounds 8 percent, and for stab wounds 2.8 percent. Most deaths were intraoperative (58 percent), with the primary cause of death being exsanguination. Multiple organ failure accounted for most of the postoperative deaths. Our 5 year study and comparison with previous studies reaffirms our belief in a conservative approach to the traumatized patient with liver injury. Utilizing the aforementioned principles, we have managed to show a continual decrease in mortality in spite of treating a more severely traumatized group of patients. We believe that continued improvement in mortality and morbidity is possible through the prevention of trauma, adherence to our basic guidelines, and the implementation of new technological advances now on the horizon     

Identification and antibiotic susceptibility of bacterial isolates from burned patients

We retrieved bacterial blood isolates from 397 adult burned patients admitted over a 7-year period. Sixty-two patients (15·6 per cent) developed true-positive bacterial blood cultures (judged non-contaminants), and of these 30 (48·4 per cent) expired. Pseudomonas aeruginosa (24 isolates), Staphylococcus aureus (19) and Klebsiella pneumoniae (19) were the most frequent isolates. In vitro susceptibilities of 149 isolates were determined to 12 antibiotics (gentamicin, amikacin, ticarcillin, piperacillin, mezlocillin, azlocillin, cefazolin, cefotaxime, ceftazidime, cefoperazone, thienamycin and ticarcillin-clavulinic acid) using agar diffusion assay. Thienamycin proved the most active agent (97 per cent of isolates susceptible). Cefoperazone was the most active cephalosporin (95 per cent susceptible). Twenty-eight organisms demonstrated multiple drug resistance; patients with such organisms had a 71 per cent mortality. Thienamycin was the most active agent against such isolates (27/28 susceptible). Susceptibilities of all 149 isolates to combinations of antibiotics were calculated, assuming no synergism or antagonism; some combinations of third-generation cephalosporins with the newer penicillins may prove to be as effective as combinations including aminoglycosides.     

Metabolism, oxygen transport, and erythropoietin synthesis in the anemia of thermal injury

The relationship between metabolism, oxygen transport, and anemia was assessed in burn patients. A significant negative correlation was found between erythrocyte 2,3 DPG, the major modulator of oxygen transport, and erythropoietin synthesis. Simultaneous bioassay and radioimmunoassay for erythropoietin revealed elevated values in the anemic burn patients. Elevated 2,3 DPG values during convalescence from thermal injury may remove the "anemic hypoxia" stimulus to erythropoieitn production, resulting in persistence of the anemia.     

Diabetic management by insulin infusion during major surgery.

In five insulin-requiring, uremic diabetic patients undergoing renal transplantation, we infused insulin intravenously at a low rate to maintain plasma glucose levels between 100 and 200 mg/100 ml. In those patients receiving 100 mg or more of prednisone per day and 5 per cent dextrose solution, the hourly infusion rate was determined from tthe following equation: insulin (U) = plasma glucose value divided by 100. When prednisone was not given or when the patient was thin, the ratio became: plasma glucose value divided by 150. Results were compared with those of nineteen similar transplant patients treated with conventional subcutaneous insulin therapy during surgery, and significantly better glucose control was achieved with the low dosage, intravenous infusion.