Thoracic outlet syndrome.

Eleven patients with vascular sequelae of thoracic outlet syndrome were operated on at the University of California, SanFrancisco, during the past 17 years. Five patients presented with episodes of ischemia of the arm and hand secondary to microemboli released from subclavian arterial lesions produced by chronic compression at the thoracic outlet. Treatment consisted of arterial reconstruction, removal of the compressive structure, and cervical sympathectomy to relieve or lessen distal ischemia. Four of the five patients had good or excellent results; one patient required amputation of the forearm. The results were inversely proportional to the extent of distal arterial embolic occlusions present at the time of surgical treatment. Six patients presented with symptoms of chronic venous hypertension. Four of the six had subclavian venous thrombosis and were treated by transaxillary resection of the first rib to decompress the collateral veins within the costoclavicular space. All four were symptomatically improved. Two patients had venous hypertension due to extrinsic compression of the subclavian vein. One patient became asymptomatic and the other was markedly improved after resection for external compression. In this small series transaxillary resection of the first rib has resulted in symptomatic improvement in chronic venous hypertension of the arm.     

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.     

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.     

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.     

Delayed aortic prosthetic reconstruction after removal of an infected graft

The amputation morbidity associated with the treatment of vascular graft infection continues to be a major clinical problem. Late amputation associated with failure of extraanatomic bypass initially required to avoid infected tissue beds might be reduced if delayed anatomic aortic prosthetic reconstruction could be safely employed. Two major concerns about this treatment option are the safety of the redo aortic reconstruction and the risk of recurrent infection in the reimplanted graft. Seven patients in whom recurrent limb ischemia or extraanatomic bypass infection developed underwent delayed aortic reconstruction using either an in-line aortic graft or supraceliac aortofemoral bypass at a mean interval of 14.5 months after removal of the infected graft. There were no perioperative deaths, and six of seven patients were well at a mean follow-up of 57 months postoperatively. All grafts remained patent throughout the follow-up period and no further amputations were required. No reimplanted graft became infected, which suggests that a reimplantation interval of 6 to 12 months may be safe. These data indicate that delayed aortic prosthetic reconstruction may be considered a safe and effective treatment option for those patients in whom limb-threatening recurrent ischemia or recurrent extraanatomic graft infection develops after treatment of aortic vascular graft infection.     

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.     

Lower extremity atheromatous embolization

Eleven patients with lower extremity atheromatous microembolization are described. The diagnostic feature of sudden, often repetitive, episodes of focal ischemia, patent major arteries of the legs, and arteriographic demonstration of nonocclusive atheromas of the proximal arterial tree are characteristic. Successful removal of the causative lesion in these patients has prevented further ischemic episodes.     

Pancreatic tumor of mesenchymal origin presenting as obstructive jaundice.

A case of an unusual tumor occurring in the head of the pancreas is presented. Definitive diagnosis could not be made, the lesion being either a low grade myxofibrosarcoma or a benign fibrous histiocytoma. The literature is discussed and several cases believed to be pancreatic sarcomata are presented, only one of which was definitely of pancreatic origin. No other case of fibrous histiocytoma of the pancreas has been reported.     

Peptic ulcer disease in kidney transplant recipients

The occurrence of peptic ulcer in kidney transplant recipients treated with corticosteroids for immunosuppression is a problem of considerable magnitude and threatens both patient and graft survival. The fact that peptic ulcer usually occurs in the early months after transplantation, and that there are known risk factors including treatment for rejection, sepsis, and hepatitis, demand a high level of clinical suspicion, early and accurate diagnosis, and prompt treatment. Aggressive medical prophylaxis is important, but if it should fail prompt reduction of the dose of corticosteroids is imperative so that continued patient survival is emphasized rather than the continued survival of the transplant. Surgical intervention, when indicated, should also be prompt, and the more definitive operations such as vagotomy with pyloroplasty or gastric resection are preferred because of a lesser occurrence of reoperation among such patients. Prophylactic operations in patients with an antecedent history of peptic ulcer may provide considerable protection against the development of corticosteroid-related ulcers after transplantation.     

Postemetic hematomas: a variant of the Mallory-Weiss syndrome.

Of forty-four patients with the Mallory-Weiss syndrome, nine (20 per cent) had endoscopic evidence of small submucosal hematoma(s) lying in or adjacent to the region of the the tear. These small hematomas are believed to occur most commonly as a variant of the Mallory-Weiss lesion.     

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.     

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.     

Prevention of complications after liver trauma

Treatment of 681 cases of liver trauma during the past ten years at the San Francisco General Hospital was reviewed. The mortality was 14.7 per cent and the morbidity rate 18.9 per cent. The complications relating specifically to liver injury were bleeding subphrenic or subhepatic abscesses, intrahepatic abscess, biliary fistula, and liver failure. These complications and the recommended management of the liver injury are discussed.     

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.     

Changing clinical spectrum of splenic abscess

In two thirds the patients with splenic abscess, the infection develops as a terminal manifestation of uncontrolled disease of other organs. These patients often have multiple small abscesses that usually produce no special clinical manifestations. Even if the existence of splenic sepsis were known, splenectomy would not benefit most of these patients.In one third the patients, pain and tenderness in the left upper quadrant of the abdomen direct attention to the spleen as the source of sepsis. Diagnosis can be confirmed by splenic scanning or arteriography and the patient can be cured by splenectomy. Contiguous infection and intravenous drug abuse are the most common causes of these curable solitary abscesses.     

Clinical manifestations of adrenal hemorrhage

Thirty-four patients with adrenal hemorrhage were treated at the University of California Hospitals, San Francisco, from 1960 through 1973. In two cases the condition was diagnosed at operation and in thirty-two the diagnosis was made at postmortem examination. In only seven of these thirtyfour patients were the abdominal symptoms and signs clearly attributable to adrenal hemorrhage. In the remaining twenty-seven patients the clinical manifestations were marked by other intra-abdominal problems or by severely altered mentation.The most common clinical manifestations in these seven patients were profound prostration, fever, mental aberrations, emesis, and weakness with severe, constant, localized, upper abdominal pain. Awareness of the sequence of symptoms and the predisposing factors of adrenal hemorrhage will make the diagnosis more apparent and treatment more successful.