Gastrointestinal anastomoses constructed with singly placed staples

Thirty gastrointestinal anastomoses were created in dogs by stapling with singly placed staples, using a commercially available skin and fascial stapler. The exercise served to illustrate the advantages of automation of individual sutures rather than the whole suture line, pointing out a new direction for the future development of gastrointestinal staplers.     

Optimal preservation of cadaver kidneys with aortic perfusion

A technique of aortic perfusion for donor kidneys has been described. This technique prevents perfusion and cannulation injuries and preserves an adequate Carrel aortic patch for use in transplantation.     

Injection sclerotherapy for control of acute variceal hemorrhage

Acute variceal hemorrhage can be controlled effectively with injection sclerotherapy using the flexible gastroscope and endoscopic balloon tamponade. The complication rate is low; however, mortality from irreversible liver failure remains high. This technique is suggested as an alternative to standard medical and operative treatment.     

The third kidney transplant

To determine the feasibility of third kidney transplantation, the experience at the University of Iowa was evaluated. The success of 14 such transplantations was dependent on the outcome of both of the previous graft operations. Three successful third transplantations with graft survival of 6 years, 3 years, and 1 year have occurred in recipients with more than 1 year survival of a previous kidney. Conversely, graft loss due to rejection developed in all patients who experienced graft survival of less than 1 year for both antecedent grafts. Moreover, HLA-A and -B matching and level of presensitization were not predictive of success in this series. These data suggest that third kidney transplantation using conventional immunosuppression may not be appropriate in the subgroup of patients who have clearly lost their first two grafts to early rejection.     

Severe abdominal vasculitis with hepatitis B antigenemia

Two cases of necrotizing abdominal vasculitis associated with hepatitis B are reported. The diagnosis of mesenteric vasculitis is often delayed, and intestinal perforation is common. Early recognition of the disease and early treatment with corticosteroid and immunosuppressive drugs may alter the course of the disease. Preoperative diagnosis is best made by mesenteric arteriography and rectal biopsy.     

Value of segmental limb blood pressures in predicting results of aortofemoral bypass

The efficacy of segmental limb blood pressure measurements, assessed noninvasively by Doppler ultrasound, in predicting the result of aortofemoral reconstruction was evaluated in fifty-two extremities with varying extent of aortoiliac and more distal arterial occlusive disease. Three prognostic correlates were analyzed: (1) preoperative proximal thigh/arm pressure index (TPI); (2) preoperative pressure gradient between adjacent leg segments (proximal thigh, above-knee, below-knee, and ankle), normally less than 30 mm Hg; and (3) early postoperative increase in the ankle/arm pressure index (API).After aortofemoral bypass, forty-one limbs (79 per cent) were asymptomatic or improved and eleven were unimproved. The mean TPI in extremities benefiting from aortofemoral bypass, 0.82 ± 0.17 (±1SD) was significantly less than that of unimproved limbs, 1.01 ± 0.09 (p < 0.01). Aortofemoral bypass was beneficial in all twenty limbs with normal leg pressure gradients. Conversely, six of twenty-five legs with one abnormal gradient and five of seven with two abnormal gradients failed to improve. The postoperative increase in API was 0.1 or more in all forty-one improved extremities and was less than 0.1 in all eleven failures. Although eleven of thirty-two limbs (34 per cent) with arteriographic evidence of combined aortoiliac and subinguinal occlusive disease were not improved after proximal bypass, the result of operation could not be predicted from the angiographic pattern or severity of distal disease. Segmental limb blood pressures provide useful predictive indices of the efficacy of aortofemoral bypass and the potential need for more distal reconstruction in multisegmental disease.     

Newer tissue and synthetic grafts in canine femoral veins

We tested double-velour Dacron, expanded polytetrafluoroethylene, gluteraldehyde-preserved human umbilical vein, and spiral composite autogenous vein against the standard of autogenous vein as segmental replacements in canine femoral veins. Technical adequacy of venous anastomoses was assessed by immediate postoperative venography. Continuous patency was assessed by venography at 3, 7, 21, and 42 days. None of the synthetic or other tissue grafts were comparable to autogenous vein in terms of early and continuous patency. Spiral vein composites had significantly better continuous patency when compared to synthetic or preserved tissue grafts. Recanalization was seen with both spiral composite autogenous vein and double-velour Dacron, but was not observed with expanded polytetrafluoroethylene or preserved umbilical vein. We conclude that: (1) these newer synthetic and preserved tissue grafts are unsatisfactory for use in the venous system, particularly in low-flow, small diameter sites and (2) spiral composites offer a simple method of constructing vein grafts of any chosen diameter which can be successful in even low-velocity flow, small diameter sites particularly when appropriately sized unmodified autogenous vein is not available.     

Simultaneous infusion of crystalloid solutions during long-term parenteral nutrition

A safer and more secure technic for the administration of additional solutions during long-term parenteral nutrition is described. This technic has contributed towards a reduction in septicemia.     

Fungal infection in burn patients: Results of using 5-fluorocytosine (flucytosine)

Fungal infection and use of 5-fluorocytosine were studied prospectively among burn patients receiving multiple antibiotics. From 22 out of 23 patients positive cultures for Candida were obtained. Cultures from the mouth and rectum became positive first. Averaging 6 days later, 16 patients had positive urine cultures. Candida in urine was the best way to detect systemic candidiasis.Nine patients received 5-fluorocytosine. Although this drug did not influence survival among patients with burns of less than 59 per cent of body surface area, it prevented death from disseminated Candida infection among patients with burns of greater than 60 per cent body surface area.Patients with large surface burns receiving multiple antibiotics should have prophylaxis against fungi. If Candida is detected in urine, systemic treatment should be given. 5-Fluorocytosine is a safe and effective systemic drug for this purpose.     

Congenital coronary artery- cardiac chamber fistula. Review of operative management.

Eight patients who had surgical correction of coronary artery-cardiac chamber fistula at our center and 163 from a review of the literature are presented. The patients are usually asymptomatic, and the diagnosis is suspected by observing a continuous cardiac murmur. Electrocardiographic findings are nonspecific. Angina pectoris or electrocardiographic evidence of severe ischemia are surprisingly uncommon since coronary artery steal syndrome is also rare. Cardiac catheterization with angiocardiography is required to establish the diagnosis and identify the involved coronary artery and the cardiac chamber into which the fistula terminates. Left-to-right shunt flow is usually low (average Qp/Qs = 1.5). Indications for operation are not precise. If there should be a large shunt flow (2.0) and symptoms of heart failure are present, the decision to operate is clearly justified. This situation is unusual, and operation is nearly always performed in an asymptomatic patient in whom the fistula is closed to prevent future symptoms or complications. The operation chosen is generally interruption of the fistula by direct ligation. Sometimes cardiopulmonary bypass is required. The results are good, with low morbidity (3.6% myocardial infarction) and low mortality (2%) justifying the operation, to be carried out prophylactically even in asymptomatic patients.     

Tissue pressure and perfusion in the compartment syndrome

Three objective indicators of the need for muscle compartment decompression were evaluated in an animal model and in clinical studies.In the animal model, there was linear correlation between compartment pressure and graded external counterpressure (r = 0.99, p < 0.001) and between decreasing MBF and increasing compartment pressure (r = -0.85, p < 0.01). MBF was undetectable with external counterpressure greater than 80 mm Hg.In patients, Doppler evaluation of distal arteries was an inconsistent guide for compartment decompression. There was correlation between MBF and the difference between diastolic blood pressure and compartment pressure (r = 0.66, p < 0.05). All patients requiring decompression had MBF values less than 1 cc/min/100g.Determination of MBF and/or compartment pressure appear to be useful early indicators of the need for compartment decompression.     

Exchange of plasminogen activator between solution and intima.

Intimal plasminogen activator depleted by mechanical injury can be restored by soaking the damaged vein in urine plasminogen activator (urokinase). This restoration occurs with little or no change in the urokinase soaking solution's other activities, vasodilation and fibrinolysis. There is some transfer of intimal plasminogen activator into solution enhancing its vasodilation and fibrinolysis. These exchanges between intimal and urine plasminogen activator activities may indicate biological and even molecular similarities between these plasminogen activators. Restoration of depleted intimal plasminogen activator may be important in clinical medicine.     

Congenital posterolateral diaphragmatic hernia past infancy

Twenty-seven cases of congenital posterolateral diaphragmatic hernia past infancy are reviewed in tabular form and discussed as to presenting symptoms, physical and radiographic findings, operative treatment, and final outcome. A ten year old male treated by us is presented as a detailed case report.A great contrast is noted between the acute respiratory symptoms which threaten life in the infant hernia compared with the more chronic and recurrent gastrointestinal and respiratory symptoms in patients past infancy. Onset of symptoms did not correlate with age or sex. Chest x-ray films and gastrointestinal contrast studies were most helpful in diagnosis. Abdominal and thoracic approaches were equally effective in reducing the herniated viscera and closing the diaphragmatic defect.We believe that long-term survival of patients with congenital posterolateral diaphragmatic hernia may be due to persistence of a confining pleuroperitoneal sac. Rupture of this sac in later life may coincide with onset of the characteristic symptoms which in turn prompt diagnostic studies. Congenital diaphragmatic hernia must be considered in the differential diagnosis of patients with both recurrent gastrointestinal and respiratory complaints. Plain radiographs of the chest and contrast studies of the gastrointestinal tract are necessary to confirm diagnosis preoperatively.     

The peripheral hemodynamics of exogenously administered prostaglandin E1 during major venous occlusion in the dog

The effects of femoral artery infusion of saline or prostaglandin E₁ (PGE₁) on femoral artery flow, mean arterial pressure, peripheral venous pressure, femoral bed vascular resistance, venous capacitance, and capillary filtration during femoral vein occlusion (FVO) were determined in the dog. FVO during femoral artery infusion of saline decreased femoral artery flow and concomitantly increased peripheral venous pressure, femoral bed vascular resistance, and capillary filtration. Intraarterial infusion of PGE₁ (3.8–5.6 ng/kg/min) during FVO attenuated the decrease in femoral artery flow and increase in femoral bed vascular resistance. The administration of PGE₁ augmented the increases in peripheral venous pressure and capillary filtration associated with FVO. Hindlimb venous capacitance was also increased by the intraarterial administration of PGE₁ during FVO. These results suggest that PGE₁ may be a useful agent in diminishing limb ischemia associated with major venous hypertension.     

Caroli's disease: A premalignant condition?

This study reports four new cases of Caroli's disease complicated by the development of cholangiocarcinoma. Caroli's disease appears to be a premalignant condition, but early diagnosis of malignancy in the cyst wall is difficult because signs of ductal stenosis develop slowly and treatment is often based on erroneous diagnosis of recurrent cholangitis. When carcinoma is present, operative intervention makes no difference in survival. In patients with Caroli's disease, adequate intraductal and hepatic biopsies should be obtained at the first operation. These patients should be followed carefully, and malignant growth should be suspected when cholangitis occurs despite patent anastomoses. Earlier diagnosis will obviate repeated operations in patients with malignant Caroli's disease.     

Radical mastectomy in a patient with coexistent Graves' disease

A patient with the coincidental occurrence of thyrotoxicosis and medullary carcinoma of the breast is reported. Survivorship was considered optimal by performance of a mastectomy without the six to eight weeks' delay required to achieve euthyroidism by antithyroid drugs or radioiodine. The hyperthyroidism was controlled with propranolol, permitting an uneventful radical mastectomy.     

Peutz-Jeghers syndrome and its complications. First case report from Malaysia with review of literature.

We report for the first time from Malaysia a patient with Peutz-Jeghers syndrome complicated by successive intussusceptions requiring extensive small bowel resection. Our experience is compared with that of other authors by a review of the literature highlighting important points in the diagnosis and management of complications in Peutz-Jeghers syndrome.     

The interaction of corticosteroids and naloxone in canine hemorrhagic shock

β-Endorphin is released concomitantly with adrenocorticotropin from the pituitary following stress and, during hemorrhagic shock, can alter cardiovascular hemodynamics. In 41 anesthetized dogs, we assessed the combined effects of pituitary suppression with dexamethasone (D) or methylprednisolone (M) and opiate receptor blockade with naloxone (N) during hemorrhagic shock. We found that N alone was the most effective treatment in improving arterial pressure, cardiac output, and left ventricular contractility and resulted in the best survival. D and M alone were little better than saline. When combined with N, D and M were better than saline but not as good as N alone. This attenuation of the N effect may be due to corticosteroid: suppression of β-endorphin and ACTH release from the pituitary; alterations in opiate metabolism; or changes in opiate receptor availability.