Gastric mucosal blood flow and Escherichia coli bacteremia

The specific changes in gastric blood flow during sepsis are controversial. Previous investigations of intragastric blood flow using endotoxin models revealed decreased total gastric blood flow and decreased gastric mucosal blood flow. Endotoxin models are now thought to be inadequate due to the accompanying depression of the systemic circulation. More recently, increased gastric blood flow has been demonstrated in a septic hindlimb model. To further elucidate the changes in intragastric blood flow in sepsis, the gastric mucosal and nonmucosal blood flow were measured in the antrum and corpus of pig stomachs before and after the onset of sepsis. Increased gastric mucosal blood flow was demonstrated in both the antrum and corpus 15 minutes after the onset of E. coli bacteremia. By 75 minutes postonset, the changes were not significant, which implied partial recovery. Clinically, gastric mucosal ulcers may accompany the multiple organ system failure of sepsis. These data suggest that mucosal ischemia is not an etiologic factor as previously postulated from experiments with endotoxin.     

Surgical management of perforated diverticulitis

The surgical management of perforated diverticulitis remains a subject of controversy, with some workers advocating initial drainage with decompressive colostomy and others favoring primary resection of the perforated colon. To evaluate this problem, we reviewed our experience from January 1, 1960 through December 31, 1978. This retrospective study included 25 patients treated by primary resection and 32 patients treated by staged resection. The duration of postoperative fever and ileus and the incidence and type of postoperative complications were similar in the two groups. Hospital stay and the period of disability were significantly shortened when primary resection with primary anastomosis was carried out initially. Overall, the total cumulative hospital stay was longer (p < 0.05) for staged resection (48 days) than for primary resection (39 days). The period of disability was also longer (p < 0.001) for staged (134 days) than for primary resection (75 days). Finally, all patients in the primary resection group left the hospital cured, that is, restored to their premorbid condition, while in the staged resection group only 75 percent were cured; 16 percent were finally discharged with colostomies and 9 percent died. These data suggest that whenever technically feasible, primary resection is the treatment of choice for perforated colonic diverticulitis.     

Microbiologic efficacy of a surgically constructed nipple valve

The efficacy of a surgically constructed nipple valve in preventing reflux of colonic bacteria into the small bowel was evaluated. The nipple valve significantly decreased the number of S. marcescens, a marker bacterium, in the small bowel when compared with plain ileocolic anastomosis. In this study, the nipple valve prevented the reflux of bacteria similar to an intact ileocecal valve which suggests that the nipple valve is an effective bacteriologic barrier and may be used as a substitute for the ileocecal valve in patients with short bowel syndrome.     

Systematic approach to traumatic hemothorax

We reviewed 395 patients with isolated hemo- or hemopneumothorax from penetrating injuries. All patients were treated with immediate insertion of a chest tube and drainage of various amounts of blood up to 1,500 ml. Forty-five patients (11 percent) were in hemorrhagic shock on admission to the hospital emergency room, and all were resuscitated with volume replacement. Twenty-one patients (5.3 percent) whose blood pressure decreased again were found on exploration to have lacerated internal mammary or intercostal arteries or major lung lacerations extending into the hilus. All other patients were treated aggressively with chest tubes, aspiration of residual blood and fibrinolytic enzymes until the lung was fully expanded. We conclude that the clinical course of patients with hemothorax after insertion of a chest tube should determine whether exploration is necessary or whether nonoperative treatment should continue.     

Pancreatic nesidioblastosis in adults. Report of a patient with hyperinsulinemic hypoglycemia

Hyperinsulinemic hypoglycemia in neonates occurs most commonly secondary to nesidioblastosis, a persistence of fetal development of the endocrine cells of the pancreas. In adults, hyperinsulinemic hypoglycemia is usually due to insulinoma or beta-cell hyperplasia. Nesidioblastosis arising in adults has only recently been reported. An adult patient with nesidioblastosis has been described. The light and electron microscopic films of this entity are shown in detail, and the embryology and treatment are discussed. Further understanding of this newly described disease entity will require research on factors that regulate the differentiation of beta cells of the pancreas.     

Gangrene of the stomach: A case of acute necrotizing gastritis

Of the several causes of gastric necrosis, the rarest is acute necrotizing gastritis which appears to be a variant of phlegmonous gastritis. In acute necrotizing gastritis all four major gastric vessels are patent, but gastric gangrene occurs secondary to an overwhelming necrobiotic infection. The case presented herein is of unusual interest because it appears to be only the third reported case of acute necrotizing gastritis with overt gangrene of the stomach. Review of the literature on suppurative gastritis emphasizes the rarity and high morbidity of acute necrotizing gastritis; the patient reported on in this study, however, survived after subtotal gastrectomy and antibiotic therapy. It is our opinion that debridement by gastrectomy must be performed in those patients with transmural, diffusely infected, nonviable gastric tissue.     

An anterior transversalis fascia repair for adult inguinal hernias

During the eight year period from 1967 to 1975, 1,020 patients more than eighteen years old underwent 1,311 inguinal herniorrhaphies. Group I consisted of 723 inguinal herniorrhaphies in which either a Bassini or a Cooper's ligament repair was used. During a four to nine year follow-up period, the total recurrence rate was 11.5 per cent; the recurrence rate for the primary repair group was 7 per cent and for the recurrent group 32 per cent. The follow-up rate was 93.7 per cent. Group II consisted of 591 herniorrhaphies in which the repair was performed by an anterior transversalis fascia technic. During a two to five year follow-up period, the total recurrence rate was 2.7 per cent; 1.8 per cent for primary repairs and 8.0 per cent for recurrent hernias. The follow-up rate was 98 per cent (95 per cent by personal examination). Assuming that the recurrences in group II will occur with the same frequency as in group I, our projected four to nine year recurrence rate is 3.4 per cent. This suggests that the anterior transversalis fascia repair results in a lower recurrence rate than either the Bassini or Cooper's ligament repairs.     

Diagnosis of chronic and postoperative osteomyelitis with gallium 67 citrate scans

The effectiveness of gallium 67 citrate in diagnosing the exacerbations of chronic osteomyelitis or postoperative osteomyelitis secondary to open reduction of fractures was tested in thirteen patients. This isotope demonstrated an area of infection in every case in which such an area existed. The control subjects consisted of patients with noninfected wounds after open reduction. In this group, gallium was not incorporated into the postoperative hematoma. No false-negative results were observed in our series, demonstrating that this element is useful in the early diagnosis of bone infections.     

Prevention of stress ulcerations using H2 receptor antagonists.

Cimetidine, an H₂ receptor antagonist, was instilled transorally into the stomachs of several groups of rats prior to a period of stress in order to study its possible prophylactic effect upon the formation of stress ulcers and its effect on gastric mucosal membrane potentials and pH. Each group consisted of seven rats. The control group (group I) was given 0.5 ml of saline every 6 hours for three days and then was stressed using a combination of restraint and cold. After the animals were sacrificed, the mean number of gastric ulcers was 7.3 and the pH of the gastric fluid was 1.3. These results were compared with the results obtained in five experimental groups of rats pretreated for varying amounts of time with cimetidine (5 mg/100 g) given every 6 hours. Group II had only two doses of cimetidine, which were then followed by a period of stress. Groups III, IV, V, and VI were pretreated with cimetidine for one, two, three, and four days, respectively, prior to stress. A statistically significant decrease in ulcers was present in those groups receiving cimetidine pretreatment for at least two days. Three additional groups were then studied to investigate the transmucosal membrane potentials of stressed rats with and without cimetidine and in a group of unstressed controls. The mean membrane potentials with and without cimetidine were ?29 mv and ?9 mv, respectively (p < 0.001), and in the group of unstressed controls the transmucosal potential difference was ?26 mv. Cimetidine, therefore, apparently protects the gastric mucosa against this decrease in the transmucosal potential difference during stress and may have a protective effect on the formation of stress ulcers. These studies suggest that cimetidine may be useful for the prevention of stress ulcers in patients subjected to severe traumatic or clinical stress.     

Surgery for bleeding duodenal ulcer

The optimal surgical therapy for bleeding duodenal ulcer is controversial. In a retrospective study, 137 consecutive patients treated surgically who were admitted with active bleeding from a confirmed duodenal ulcer were analyzed. Eighteen patients (13.1 per cent) underwent truncal vagotomy-pyloroplasty, 109 (79.6 per cent) Billroth II gastric resections with or without truncal vagotomy, and 10 (7.3 per cent) other procedures. The average age was 61.2 years for those undergoing vagotomy-pyloroplasty and 51.9 years for those undergoing gastric resection (p < 0.02). Overall mortality was 5.6 per cent for the former group and 6.4 per cent for the latter (p > 0.8). The average preoperative blood replacement was 4.37 units. Patients older than seventy years had a mortality of 33.3 per cent ($\text{6}\text{18}$), and patients less than seventy years had a mortality of 3.4 per cent (p < 0.0005). These two groups were again analyzed according to each operative procedure. There was no difference in sex ratio or in the amount of preoperative transfusion between the groups. In patients less than seventy years old the mortality of those with vagotomy-pyloroplasty ($\text{1}\text{12}$) was not significantly different from the mortality of those with gastric resection ($\text{2}\text{99}$) (p = 0.2). In patients more than seventy years old the mortality of those with vagotomy-pyloroplasty ($\text{0}\text{6}$) was significantly less than the mortality of those with gastric resection ($\text{5}\text{10}$) (p < 0.05). There was no age difference between the survivors and nonsurvivors in patients with vagotomy-pyloroplasty. The survivors with gastric resection were 20.9 ± 1.3 years younger than the nonsurvivors (p < 0.05). These data suggest that vagotomy-pyloroplasty is safer than gastric resection for the surgical treatment of bleeding duodenal ulcer in patients more than seventy years old. For patients less than seventy years old, there was no difference in mortality between the two procedures.     

The rationale against routine subtotal parathyroidectomy for primary hyperparathyroidism

Our therapeutic approach to the treatment of primary hyperparathyroidism has been the resection of only the abnormally enlarged parathyroid gland, the normal-appearing parathyroids being left intact. During the past twenty-five years we have operated on 292 patients with primary hyperparathyroidism. In all cases the serum calcium levels returned to within normal limits during the immediate postoperative period, and there were no instances of permanent hypoparathyroidism. To determine the long-term efficacy of this therapeutic approach, a retrospective study of 101 patients operated on for primary hyperparathyroidism during a nine year period from July 15, 1965 through June 30, 1974 was made. Of the 101 patients, eight were dead and nine could not be located. Of the remaining eighty-four patients, only two required reoperation because of recurrent hypercalcemia; one had MEA-I and eventually three and a half glands were removed, and the other had recurrent hypercalcemia after a three year normocalcemic interval, and after a second operation with resection of an enlarged parathyroid gland, he has remained normocalcemic. The other eighty-two patients (97 per cent of those reevaluated and 82 per cent of the total operated on) have remained symptom-free and normocalcemic for periods ranging from three to twelve years. Only one patient (if we exclude the patient with MEA-I) has elevated serum parathormone levels with borderline levels of serum calcium. Our results suggest that the optimal surgical treatment of primary hyperparathyroidism, except for cases of MEA, is resection of only the abnormally enlarged parathyroid glands after exploration and identification of all four glands in every case. If all four glands are enlarged, three and a half should be resected.     

Carcinoma of the thyroglossal duct

Seven patients with carcinoma in a thyroglossal duct cyst have received treatment over a 15 year period. Findings in all of these patients reflect the likelihood of carcinoma arising within thyroglossal duct tissue. In each patient there was sufficient histologic evidence of the presence of a thyroglossal duct cyst and carcinoma arising within an intimate admixture of normal thyroid tissue in the cyst wall. In the absence of a history of irradiation and with separation of the carcinoma from the pyramidal lobe of the thyroid, excision of the thyroglossal cyst alone by traditional means seems appropriate. Our experience as well as a review of reported cases to date indicate that distant metastases are extremely rare and the prognosis excellent.     

Combined Valve and Coronary Artery Surgery

From 1970 to 1978, 79 patients (Group 1) underwent combined valve replacement and coronary bypass operation. They were compared with 79 consecutive subsequent patients (Group 2) undergoing similar valve replacement. In Group 1, 73% were men compared with 48% in Group 2. The average age in Group 1 was 60 years (range, 42 to 84 years) and in Group 2, 57 years (range, 29 to 74 years). When the patients were first seen, angina was present in 49% in Group 1 and only 24% in Group 2. More than 95% of the patients in both groups were in New York Heart Association Functional Class III or IV. Areas of abnormal contraction were twice as frequent in the angiograms of patients in Group 1 (43%). Thirty-three mitral, 44 aortic, and 2 aortic plus mitral valve replacements were performed in each group. One to 4 grafts were placed in each patient in Group 1, and most had single or double grafts. Early morbidity was more frequent in Group 1. Early mortality was 5 to 6% in each group. Late mortality (average, 3.5 years after operation) was 16 to 17% in each group. The working status and Functional Classification at follow-up were similar for patients in both groups. Combined valve and coronary operation carried a similar operative risk and had similar late results as valve replacement alone.     

Effect of starvation on the local and systemic metabolic effects of the lambda-carrageenan wound

The contribution that starvation makes to the altered glucose metabolism in injured rats was evaluated. Food intake, weight change, nitrogen balance, and muscle tissue concentrations of glycogen, glucose, and the glycolytic intermediates were determined in these animals. This study concluded that the wounded and pair fed control groups presented adequately represent the metabolic states associated with injury and semistarvation in experimental animals, decreased food intake plays a major role in the weight loss and nitrogen balance in this wound model, wounding overrides two of the controlling steps of glycolysis (hexokinase and phosphofructokinase) in skeletal muscle during starvation, the finding of similar pyruvate dehydrogenase activity after wounding and starvation as demonstrated by tissue lactate to pyruvate ratios and lactate and pyruvate concentrations suggest that lactate production in wounded tissue may not be simply a manifestation of an altered redox state secondary to anaerobic conditions.     

Pulmonary Sequestration Causing Congestive Heart Failure in Infancy: A Report of Two Cases and Review of the Literature

Congestive heart failure as a presenting symptom in infants with pulmonary sequestration is rare, and the cases of only 3 such patients have been reported. The clinical features, hemodynamics, and management of two additional patients are described. Both were seen in severe congestive heart failure in the absence of any associated cardiac anomalies. The physical findings, plain roentgenograms, electrocardiograms, and echocardiograms may provide some diagnostic clues, but cardiac catheterization is the essential diagnostic investigation. In 1 patient, pneumonectomy was performed because of extensive changes throughout the affected lung. In the other, ligation of the anomalous systemic artery to the sequestered lobe was the only surgical procedure. Both patients are doing well 15 months and 18 months after operation. Success with the latter surgical approach has not been reported previously.     

A transsternal approach to the upper thoracic vertebrae

An anterior surgical approach to the upper thoracic vertebrae has been described. A T-shaped skin incision is used, with the horizontal limb 1 cm above the clavicle, and the vertical limb extending in the midline over the body of the sternum. A portion of the manubrium sterni, as well as the medial third of the clavicle, is resected; the avacular tissue plane between the carotid sheath laterally and the trachea and esophagus medially is developed to reach the prevertebral space. After surgery, immediate fusion is performed using the clavicle and manubrium. This procedure is well tolerated, and was associated with minimal morbidity and no mortality in a series of seven patients.     

Secretory effects of intravenous serotonin on the proximal jejunum of the awake dog

The intestinal secretory effects of hyperserotoninemia were studied in conscious dogs with cannulated, exteriorized chronic proximal jejunal segments. A basal absorptive state for water and electrolytes was significantly changed to a secretory state for water, sodium ion, chloride ion, and potassium ion when serotonin was infused intravenously at 30 micrograms/kg per minute. This effect disappeared with the cessation of the infusion. During infusion, whole blood serotonin concentrations were similar to those in patients with the carcinoid syndrome. Diarrhea developed in all animals studied during infusion, and significant hypokalemia also occurred. These results support a primary role for serotonin in the pathogenesis of diarrhea associated with the carcinoid syndrome.     

Malabsorption secondary to Meckel's diverticulum

This case report of a patient with a large Meckel's diverticulum with associated stagnation and bacterial proliferation demonstrates the resultant metabolic and nutritional alterations that have classically been described with the blind loop syndrome. A lesion as large as the one presented herein has rarely been reported with iron, vitamin B₁₂, and folic acid deficiency anemias secondary to the contaminated small bowel (ileum) syndrome. A discussion of the pathophysiology, diagnosis, and treatment of this disorder and the multiple disease entities incorporated in the contaminated small bowel syndrome are included.     

Effectiveness of normal saline solution, dextran 40 or dextran 75, and aprotinin (Trasylol) on renal blood flow preservation during acute canine pancreatitis

A decrease in renal blood flow is believed to be important in the genesis of the acute renal failure of acute pancreatitis. In some instances, this decrease is undoubtedly due to hypovolemia, whereas in other instances, a circulating vasotoxic agent, possibly trypsin, has been incriminated. Using a canine model of pancreatitis induced by retrograde injection of bile along the pancreatic duct, the effects on renal blood flow of correcting the hypovolemia or administering aprotinin (a trypsin inhibitor) were studied using externally applied flow probes. Correcting the hypovolemia with N saline solution had no effect; the renal blood flow continued to decrease (p less than 0.05). When dextran 40 or dextran 75 was employed, the decrease in renal blood flow was prevented. After the administration of aprotinin, the renal blood flow actually increased (p less than 0.025) compared with preadministration values. It appears that aprotinin may have played a role in preventing this serious complication of pancreatitis.