Colon perforation in renal transplant patients.

Seven patients had perforated colonic diverticula 1 to 17 months after transplantation. Operation was performed immediately in four patients and from 4 days to 3 months later in three patients. Three patients are alive 9 to 36 months later. Two died of sepsis and two of myocardial infarction. Immediate operation with exclusion carries the best prognosis.     

Sequestrectomy and hyperalimentation in the treatment of hemorrhagic pancreatitis

Surgical treatment has been used in those patients with hemorrhagic pancreatitis who deteriorate after several days of intensive medical therapy, or in those patients in whom the diagnosis cannot be established early in the course of treatment. Initial therapy consisted of: cholecystostomy or T-tube drainage in those patients who have gallstones, jaundice, or distended biliary tree; gastrostomy for prolonged gastric decompression; jejunostomy to provide a portal for enteroalimentation; and appropriate soft rubber drainage of the pancreatic bed as a simple, safe, and effective means of treating severe hemorrhagic pancreatitis. Adjunctive daily hyperalimentation and later sequestrectomy of necrotic pancreatic tissue provided a mortality of 20 per cent and complete rehabilitation of sixteen of thirty patients so treated. Delaying the initial approach to necrotic pancreas allows precise delineation of necrotic material so that sequestrectomy, leaving behind normal pancreas, can be carried out to avoid exocrine and endocrine deficiencies after the acute episode has passed.     

Agenesis of the gallbladder,malrotation of the gut,and horseshoe kidney: A new syndrome?

A fifty-one year old woman presented after eight months of aching pain in the right upper quadrant and two nonvisualizing cholecystograms. She underwent operation for presumed cholecystitis. At operation, nonrotation of the large intestine was found and the cecum and appendix were in the left upper quadrant. Duodenal bands were present. Most of the small bowel lay beneath a saclike covering in the right side of the abdominal cavity. Careful examination of the retroperitoneum, including the posterior portion of the pancreas, retroduodenum and retroperitoneum, and both lobes of the liver, revealed no gallbladder tissue. The portal vein lay anterior in the hepatoduodenal ligament. Postoperative intravenous cholangiogram, upper gastrointestinal series, and barium enema confirmed the nonrotation and the normal biliary tree with no filling of gallbladder structures. A renal study demonstrated a horseshoe kidney. Similar cases reported by Seifert [4] and Reid [11] may indicate some common association of developmental abnormalities.     

Inflammatory tissue reaction in rabbit bowel injected with Crohn's homogenates.

Homogenates from the terminal ileum of a patient with Crohn's disease with granulomas were prepared as snap-frozen or fresh and were injected into the ascending colonic walls of New Zealand white rabbits. Control animals were injected with 1 per cent bovine serum albumin alone. The rabbit bowel was examined after 1 year, and lesions were noted in each of the rabbits injected with Crohn's disease homogenate, irrespective of the type of tissue preparation. The observed lesions were diffuse and occurred both at the injection site and in the terminal ileum. These changes were not noted in the control group. This work confirms earlier results in the same animal model and suggests that either fresh or snap-frozen homogenates will produce the intestinal lesion but that bovine albumin alone will not.     

A stomal appliance for provisional ileostomy in neonates of low weight at birth who require temporary ileostomy.

In the surgical treatment of infants of low weight at birth for various congenital or acquired intestinal defects, it occasionally becomes necessary to divert intestinal contents by temporary ileostomy. There are no commercially available stomal appliances that are suitable for patients of this size. A rapid and easy method of constructing such an appliance is presented. The appliance protects peristomal skin, reduces nursing skin care time, and provides an easy and efficient method of collecting and measuring stomal affluent.     

Deep hypothermia in cardiovascular surgery

Recent experimental studies and clinical application of deep hypothermia for cardiovascular surgery are reviewed. At most institutions, surface hypothermia alone or in combination with limited cardiopulmonary bypass has been employed. Circulatory dynamics were well maintained following prolonged cardiac arrest at 20°C. Some degree of acidosis usually developed after the arrest period but was gradually corrected during rewarming. Total circulatory occlusion could be maintained for at least one hour at 20°C. without evidence of cerebral damage in infants. Many complex congenital cardiac anomalies, including transposition of the great arteries, total anomalous pulmonary venous return, ventricular septal defect, and tetralogy of Fallot, have been successfully corrected in the first few weeks of life. Less encouraging results have been achieved in patients with infradiaphragmatic total anomalous pulmonary venous return, complete atrioventricular canal, or pulmonary atresia.     

Oxygen utilization during surface-induced deep hypothermia

Oxygen utilization during surface-induced deep hypothermia under ether anesthesia and respiratory alkalosis, with and without 30 minutes of circulatory arrest, was studied in 12 dogs. Oxygen consumption and saturation, hemoglobin, hematocrit, Po₂, Pco₂, and pH of arterial and mixed venous blood were measured, and oxygen content, arteriovenous oxygen differences, and cardiac output were calculated.There were slightly decreased but persistent arteriovenous oxygen differences during cooling until low cardiac output developed around 18°C., which would suggest continued unloading of oxygen from hemoglobin despite the presence of severe alkalosis. The oxygen debt developed during total circulatory occlusion or from low cardiac output was repaid in the early rewarming period when circulation was reestablished. Venous Po₂ became progressively lower below 25°C. Tissue oxygen uptake is presumably accomplished by lowering tissue oxygen tension, but this drop apparently does not grossly impair tissue function since all dogs tolerated the procedure well and are long-term survivors.     

Pyogenic osteomyelitis of axial bones following civilian gunshot wounds.

A series of forty-five patients with low velocity gunshot wounds to the spine and pelvis were followed up for at least eight weeks to determine the incidence of pyogenic osteomyelitis and the role of debridement and fragment removal in its prevention. Four cases of osteomyelitis were found, and although debridement was not frequently done, the incidence of osteomyelitis was higher following debridement than it was without debridement. The most important cause appeared to be spread of contiguous intraabdominal abscesses into the injured paravertebral muscles and spine. If an intraabdominal abscess did not develop, the presence of gastrointestinal injury did not predispose the patient to osteomyelitis. Based on this study, we can conclude that debridement and fragment removal of the spine and pelvic bones are unnecessary for low velocity missile wounds.     

Extremity necrosis caused by indwelling arterial catheters.

Four patients sustained tissue due to indwelling catheters, three of which were in radial arteries and one of which was in the dorsalis pedis artery, In one of the patients, septic thrombosis was demonstrated. The risk of such complications can be minimized by precannulation evaluation of the arterial circulation of the extremity, by proper care of the catheter when in place, and by careful observation for clinical evidence of infection, ischemia, and other treatable problems.     

Choledochal cysts presenting in late childhood and adulthood

Primary excision is well accepted in children. Although the length of follow-up is inadequate, our review of the literature and experience with five patients suggests primary excision as the procedure of choice in older children and adults. Although the number of cases is too small and the follow-up too sporadic to draw statistically valid conclusions, excision has a lower morbidity, mortality and reoperation rate than internal cyst drainage, and definitive removal of tissue at risk for malignant degeneration seems intuitively more appealing.     

Use of radionuclide lymphograms to determine lymphatic drainage of truncal melanomas

Radionuclide lymphograms provide invaluable preoperative information on many truncal melanomas of the skin that require elective regional lymph node dissection.     

Natural history of incidental appendectomy in patients with Crohn's disease who required subsequent bowel resection

The records of 20 patients with Crohn's disease who underwent incidental appendectomy and later required bowel resection were reviewed and the following conclusions ascertained. If the patient had had abdominal pain for less than 1 week, appendectomy is followed by minimal problems. If the patient has had abdominal pain for longer than 1 week, incidental appendectomy is followed by an 83 percent incidence of fistula or sinus tract, arising not from the appendiceal stump but from the terminal ileum. The natural history of patients with resection after appendectomy includes more medication and a higher symptom recurrence rate and perhaps operative recurrence rate than their counterparts who have not undergone incidental appendectomy.     

Noninvasive carotid bifurcation mapping. Its relation to carotid surgery

The carotid bifurcation can be studied accurately by a noninvasive Doppler mapping procedure. Areas of plaquing and stenosis can be located and flow patterns and alterations in velocity can be assessed equally.The technic described is valuable in many clinical settings to aid in the detection and prevention of potential stroke. It is not designed to subordinate standard cerebral angiography but to complement it. The Doppler carotid survey is easy to perform, reliable in its reproducibility, and designed to detect not only morphologic changes but also functional abnormalities of blood flow.