Restoration of strong grasp and lateral pinch in tetraplegia: a comparison of two methods of thumb control in each patient

Six patients with spinal cord injury who ranged in age from 25 to 42 years were selected for surgery that used a tendon transfer for opposition-adduction of one thumb and arthrodesis of the carpometacarpal joint of the other in each patient. At follow-up 2 to 6 years later, the hands with the opponens-adductorplasty had a slightly stronger lateral pinch (3.75 kg versus 3.31 kg), but the hands with the carpometacarpal arthrodesis had a somewhat stronger grasp (7.42 kg versus 6.86 kg). The patients did not exhibit a consistent preference for either method, but rather, were particularly pleased that their hands had been reconstructed differently, thereby allowing each to be somewhat "specialized" for certain activities.     

Diagnostic and surgical aspects of insulinoma. A review of twenty-seven cases

The clinical features of twenty-seven patients with insulinoma are discussed. The best diagnostic test is a seventy-two hour fast with multiple determinations of blood glucose and insulin. Preoperative arteriography and intraoperative blood glucose monitoring are recommended in all patients. In the present series there was no operative mortality, and all patients were rendered asymptomatic.     

Pancreatic transplantation without duodenum in the dog

Our study has shown that it is possible to maintain normal exocrine and endocrine function in pancreatic heterotopic auto- and allotransplants without duodenum in the dog using a small periampullary duodenal cuff sutured directly to jejunal mucosa. The described technic has been used to prepare human cadaver donors and further clinical trials are anticipated.     

Reflux gastritis: the consequences of intestinal juice in the stomach.

The consequences of exposure of the intact stomach to intestinal contents were examined in six dogs. Diversion of duodenal contents through the stomach lead to the following changes: histologic gastritis in both antrum and corpus, increase in resting and postprandial serum gastrin levels, increased parietal cell density in four of six animals, and enhanced maximal acid secretory capacity in three of six animals. No significant changes were seen in insulin-stimulated acid secretion, insulin-stimulated pepsin secretion, antral gastrin levels, or G cell numbers. We conclude that chronic exposure of the intact stomach to duodenal contents results in gastritis and an amplified gastrin response to food. Parietal cell numbers and maximal acid secretory capacity are increased in some animals.     

Absorption of carbohydrates and vitamins in the preserved and transplanted small intestine

A significant impairment in the intestinal absorption of D-xylose and vitamin A was observed in the first weeks after preservation and transplantation of the whole small bowel. Functional recovery was only observed in long-term survivors, usually transplanted dogs that lived more than five weeks. There was no impairment in the absorption of vitamin B₁₂. Only prolonged survivors showed low normal limits of vitamin B₁₂.     

A new solid-state, long-life, lithium-powered pulse generator

A pulse generator powered by lithium iodide and using hybrid circuitry eliminates many of the causes of premature failure of pulse generators. The lithium iodide power source is completely dry, produces no gas, has no significant self-discharge, shows no catastrophic failure, is most efficient at body temperature, and loses power in a gradual fashion, thus giving months of foreknowledge of impending failure. The hybrid circuitry eliminates most soldered connections, which increases efficiency, reduces sources of failure, and allows a smaller pulse generator to be produced. The entire system can be hermetically sealed because no outlet for gas is required. The calculated in vitro life of this system is greater than 10 years, while a conservative estimate of in vivo life is 5 years.     

Dorsal carpal dislocation and flexor tendon rupture in rheumatoid arthritis: a case report

A unique case of dorsal carpal dislocation of a rheumatoid wrist with an unusual pattern of flexor tendon rupture and median nerve compression is reported. The carpus was relocated and fused to the radius. The distal ulna was resected. Grafting and adjacent suturing of the tendons restored function, but late follow-up showed development of secondary deformities.     

Understanding the bowel obstruction problem.

Tools to cope more effectively with the bowel obstruction problem have been gradually evolving over the past four decades. It is possible to recognize most varieties of acute intestinal obstruction early enough to salvage the patient from the threat of a disorder that a few decades ago commanded a forbidding mortality. Great intestinal distention does not loom as difficult a problem today as it did four decades ago.The large residual mortality of intestinal obstruction today concerns primarily strangulating varieties. In fact, more than half the deaths from intestinal obstruction derive from the profession's failure to deal promptly with strangulated hernias and with internal strangulations before the bowel becomes nonviable. The current achievement with intussusception contrasts strikingly with our failure to deal competently with other strangulating varieties of intestinal obstruction. So similarly, the accomplishment with congenital intestinal atresia bespeaks the finesse of modern-day surgeons in coping with anastomoses of small tubular structures.The profession needs to take a more serious interest in intubation technics in dealing with intestinal distention, to which developments my colleagues, Doctors Arnold Leonard and Richard Edlich, have made significant contributions.The team approach to the problem of intestinal obstruction is essential. Every hospital with an interest in intestinal obstruction should have on its Bowel Obstruction Team an intestinal intubator with both interest and expertise. Leonard and Edlich and others who have achieved striking success with intestinal decompression by per oral intubation have a responsibility to train intubators and to transmit their expertise to others who can carry on. The problem in many respects is not unlike the history of utilization of gastroscopy for diagnosis. Only within the past decade have most American hospitals enjoyed ready access to competent gastroscopists, despite the fact that Mikulicz's first effort with gastroscopy traces back more than a century. It is important to preserve the skill and expertise that experienced intubators have acquired. Their lessons and experience will be lost unless transmitted to younger professional associates.Early diagnosis, prompt surgical management of all strangulated hernias, and per oral decompression of the distended small bowel prior to and/or at operation in all simple obstructions are fundamental criteria for success in any plan of treatment. When the obstruction is complete, after operative decompression, the obstructing mechanism must be removed surgically. For incomplete simple obstructions of the small intestine following adequate decompression, operation may not be necessary. Most instances of paralytic ileus, not septic in nature, respond favorably to conservative management. In colic obstructions, early decompression proximal to the obstruction is indicated. Effective intestinal decompression, preserving the sterility of the peritoneal cavity lies at the root of the matter.This recounting of a long experience in attempting to understand the bowel obstruction problem suggests that clinical observation, reinforced by experimental studies, is a useful tool in lending a forward thrust to improved accomplishment.     

Treatment of heterozygous type II hyperlipidemia by partial ileal bypass in a pediatric population.

Nine patients underwent partial ileal bypass as management for heterozygous type II hyperlipidemia. The average age of this group was 12.5 yr. Follow-up has ranged from 1 to 6 yr. The growth and development of these children proceeded normally. The overall average serum cholesterol reduction was 33% when compared to the preoperative but postdietary control value. Side effects of the procedure include transient diarrhea and inability to absorb vitamin B12, requiring periodic parenteral administration. Partial ileal bypass has been shown to be an effective and obligatory method of treatment of hypercholesterolemia in children.     

Kidney transplantation from living related donors with multiple vessels. A problem revisited

Thirty-one renal transplantations were performed using kidneys from living donors with known bilateral double renal arteries. In twenty-one patients both vessels were anastomosed but in ten patients a tiny polar vessel was sacrificed resulting in a small infarct in the grafted kidney. Results of transplantation in these patients were compared with those in recipients of related and cadaver kidneys matched for time of transplant, sex, and age of recipient. There is an increased incidence of acute tubular necrosis in recipients of transplants from living donors with double renal arteries. By several weeks after transplantation, however, renal function is identical to that in recipients of related donor organs with single arteries. Hypertension that is more common in patients with double renal arterial anastomoses is relatively easy to control with increased antihypertensive medications. Two patients had loss of the kidney transplants because of stenosis of one or both renal arterial anastomoses. Despite these losses, the results of renal transplantation from living related donors with double renal arteries are almost as successful as those from a related donor with single renal arteries.In contrast, recipients of kidneys with polar infarcts appear to undergo more episodes of rejection, infection, or both, than do recipients of related transplants with single renal arteries. In one patient with a polar infarct, delayed total ureteral necrosis developed.Living related donors with bilateral double renal arteries should be accepted as donors in preference to cadaver donors if both vessels can easily be anastomosed. If, however, a polar vessel must be sacrificed, it is suggested that a cadaver donor be utilized in preference to a related donor.     

Lipid effects of obesity operations

To achieve weight reduction, and specifically to lower blood lipids, we performed the first 40- to 4-cm end-to-end jejunoileal bypass in August 1970. Since 1975 we have also used gastric bypass, modified from Alden, for weight reduction. Lipids from 205 jejunoileal bypass and 106 gastric bypass patients have been sequentially analyzed from 1 to 3 years postoperation. After jejunoileal bypass cholesterol was lowered 33% by 6 weeks after surgery (P < 0.001). By 12 months, the cholesterol was lowered 42% from a preoperative value of 189 ± 35 (mean ± 1 SD in mg%) to 110 ± 27, n = 205 → 159, P < 0.001; this reduction was maintained through 36 months postbypass. At 12 months after bypass the other lipids showed similar lowering: total serum lipids, 37% (from 677 ± 181 to 425 ± 106, n = 189 → 158, P < 0.001); phospholipids, 34% (220 ± 47 to 146 ± 35, n = 162 → 137, P < 0.001); SF 0–12 lipoproteins, 30% (275 ± 70 to 194 ± 47, n = 162 → 118, P < 0.001); and SF 12–400 lipoproteins, 42% (from 188 ± 14 to 110 ± 63, n = 162 → 118, P < 0.001). The gastric bypass also resulted in lipid lowering during the first year after the bypass operation. The cholesterol values were lowered 14% (from 191 ± 30 to 165 ± 31 mg%, n = 106 → 51, P < 0.001); total serum lipids, 20% (675 ± 138 to 541 ± 115, n = 82 → 36, P < 0.001); triglycerides, 35% (176 ± 98 to 114 ± 63, n = 106 → 51, P < 0.001); phospholipids, 17% (225 ± 39 to 186 ± 43, n = 79 → 36, P < 0.001); SF 0–12 lipoproteins, 21% (310 ± 85 to 245 ± 80, n = 71 → 28, P < 0.001); and SF 12–400 lipoproteins, 48% (170 ± 89 to 88 ± 99, n = 70 → 28, P < 0.001). Thus, both jejunoileal and gastric bypass lower the blood lipids, however, the jejunoileal effect is generally greater; specifically, the cholesterol reduction after jejunoileal bypass is three times that engendered by gastric bypass.     

Postinfarct enzyme elevation in coronary sinus blood

The diagnosis of myocardial infarction in the postoperative period is difficult in the absence of significant electrocardiographic changes. The advent of direct coronary artery surgery has been associated with a relatively high incidence of postoperative myocardial infarction. In order to detect myocardial necrosis better, it was proposed that sampling of blood from the coronary sinus would identify a higher level of serum enzymes [serum glutamic—oxaloacetic transaminase (SGOT), lactic dehydrogenase (LDH), heat-stable LDH, and creatinine phosphokinase (CPK)] associated with myocardial damage than would sampling of peripheral blood and that the elevation would appear sooner after injury.Thirty-two dogs were studied to test this hypothesis. In half of the animals, myocardial infarction was induced by injection of mercury into the circumflex coronary artery. The other half received saline injections into the coronary artery. All dogs underwent simultaneous serial sampling of coronary sinus and peripheral venous blood. Variations in the amount of surgical manipulation and in the time intervals between sampling were carried out. No significant pattern of enzyme elevation could be detected which differentiated the surgical animals sustaining infarction from the control animals, other than that established by the heat-stable (HS) fraction of LDH. However, all too frequently in the clinical setting, the HS-LDH levels cannot be utilized due to hemolysis and variation of LDH levels with each surgical procedure. The levels of enzymes in coronary sinus blood did not differ significantly from those in peripheral venous blood in any group of animals with myocardial infarction.In summary, these experiments demonstrated no statistically significant difference in enzyme levels in coronary sinus versus peripheral venous blood following myocardial infarction in the dog. Surgical procedures obscured the enzymatic picture of infarction. Patterns suggesting infarction associated with surgery could be distinguished but definite criteria could not be established. It is suggested that further investigations be carried out to decide definitively if the cardiac lymph is the major site of drainage of enzymes following myocardial necrosis.     

The relationship of lumenal pH and distention to antral G-cell numbers

This study was designed to study the importance of lumenal pH and antral distention on G-cell numbers. Antrocolic transpositions (ACT) were performed in female Sprague-Dawley rats, orienting the peristalsis of the transposed antra to result in either filling or emptying. In some animals a segment of parietal cell bearing corpus mucosa was left with the antrum to provide a relatively acid lumen. Sham operations were performed in controls. The rats were sacrificed after 15 days. The self-filling antra were grossly distended compared with the self emptying antra. G cells were quantitated by means of a double-antibody immunofluorescence technique. All ACT rats had significantly increased G-cell numbers and serum gastrin levels compared with controls. The magnitude of the increase depended on the presence or absence of distention and an acid environment. The most marked hyperplasia occurred in the group with distended antra and no acid. The group with self-filling antra but an acid lumen showed a significant but lesser increase. The least degree of hyperplasia was observed in the group with self-emptying antra and an acid lumen. These data indicate that both distention and a nonacid lumenal pH encourage G-cell hyperplasia. The nonacid lumen is a more potent stimulus than distention but the two are synergistic.     

Protection of the ischemic liver by donor pretreatment before transplantation

Canine livers ischemically damaged for thirty minutes prior to auxiliary transplantation did not survive for long periods of time unless a combination of isoproterenol, allopurinol, and heparin was administered intravenously to the donor animal before the ischemic damage. These drugs had no protective effect when given individually. Ischemic livers treated with adenosine prior to transplantation also showed no improved recovery of function.     

Povidone-iodine in peritonitis. I. Adverse effects of local instillation in experimental E, coli peritonitis.

Lethal quantities of undiluted povidone-iodine solution ip appear to cause mortality by inducing a chemical peritonitis with resulting hypovolemic shock. Sublethal doses of polyvinyl-pyrrolidone-iodine (PVP-I) given synchronously with Escherichia coli increased the mortality of E. coli or E. coli-hemoglobin peritonitis. Pretreatment of the peritoneal cavity with dilute PVP-I reduced the mortality of E. coli peritonitis, but this appears to be a nonspecific effect, since PVP-I in sublethal quantities is rapidly neutralized within the peritoneal cavity. Our single attempt at operative lavage with dilute PVP-I increased the mortality of E. coli peritonitis induced 1 hr earlier.     

Tuberculous joint disease in transplant patients.

Three patients with tuberculosis, all manifesting monarticular joint involvement, among 845 renal allograft recipients at the University of Minnesota are reported on. Clinical symptoms, methods of diagnosis, and optimal antibiotic regimes are discussed. The physician must suspect tuberculous joint disease when confronted with monarticular swelling and pain in the transplant recipient.     

Aneurysms of the gastroduodenal and pancreaticoduodenal arteries

The operative management of an aneurysm of the gastroduodenal artery and an aneurysm of the pancreaticoduodenal artery is discussed. There are only eight cases of gastroduodenal artery aneurysms and eighteen cases of pancreaticoduodenal artery aneurysms in the literature. Because of the difficulty in making a clinical diagnosis, even after exploratory laparotomy, we stress the importance of the use of angiography in the final diagnosis. We also emphasize the necessity of aggressive operative management after a diagnosis of aneurysm of the splanchnic artery has been made, because of the high incidence of rupture and possible death.