Effect of operations for variceal hemorrhage on hypersplenism

Hypersplenism frequently accompanies cirrhosis with portal hypertension. In this series of 76 patients, 36 percent had thrombocytopenia, 41 percent had leukopenia, and 25 percent had both thrombocytopenia and leukopenia. However, hypersplenism was severe enough to necessitate splenectomy in only two patients (3 percent).Nonalcoholic cirrhotic patients exhibit hypersplenism more frequently and to a greater magnitude than do alcoholic cirrhotic patients. Fourteen and 44 percent of alcoholic and nonalcoholic cirrhotics, respectively, had both thrombocytopenia and leukopenia. Distal splenorenal shunts and nonselective shunts are equally effective in relieving preoperative hypersplenism. Approximately two thirds of the patients were relieved of thrombocytopenia or leukopenia after either of these procedures. Splenectomy invariably corrects hypersplenism associated with cirrhosis and should be included as part of the operative procedure in patients requiring surgery for control of variceal hemorrhage.     

Effect of portasystemic shunt operations on hepatic portal perfusion

We recently developed a radiocolloid technique for quantifying the fraction of superior mesenteric venous blood that bypasses liver sinusoids through extra- and intrahepatic collateral vessels. In the present investigation we applied this method, which is performed in conjunction with visceral angiography, to the assessment of patients with portal hypertension before and after surgical construction of portasystemic shunts. The mean corrected shunt index was 0.89 in 27 preoperative patients, and 48 percent of the patients had no evidence of sinusoidal perfusion by superior mesenteric venous blood (shunt index greater than 0.95). Sinusoidal perfusion was absent in five patients with residual hepatic portal flow by angiography, indicating that they had a high degree of intrahepatic shunting. Hepatic portal perfusion was preserved in 80 percent of patients after distal splenorenal shunt, and the corrected shunt index was significantly smaller after this procedure than after portacaval and interposition shunts. Three patients with no sinusoidal perfusion by superior mesenteric blood preoperatively had restoration of portal flow after distal splenorenal shunt. Five patients undergoing portacaval and interposition shunts had no evidence of portal sinusoidal perfusion by the radiocolloid technique either before or after the operative procedure.     

Success of medical and surgical management of acute variceal hemorrhage

Peripheral intravenous Pitressin infusion, use of the Sengstaken-Blakemore tube, or both effectively controlled variceal hemorrhage in 69 percent of patients, allowing an interval of medical management before elective portasystemic shunt surgery. Prolonged preoperative in-hospital management significantly improved hepatic function in initially poor risk patients. This improvement in hepatic function appeared to result in decreased postoperative morbidity and an operative mortality equal to that of good risk patients.     

Surgical therapy for chronic pancreatitis: Selecting the appropriate approach

Surgical therapy of 37 patients with chronic pancreatitis is reviewed. Procedures included longitudinal pancreaticojejunostomy (10), DuVal (5), distal resection (4), pancreaticoduodenectomy (2), sphincteroplasty (7), pseudocyst drainage (6) and other miscellaneous procedures. Complication rates were 30 percent for lateral pancreaticojejunostomy, 28.5 percent for sphincteroplasty and 72.7 percent for resection procedures. The overall complication rate was 54.5 percent, and there were two deaths (5.4 percent). Follow-up is presented on 20 patients, of whom 16 are improved, 2 are unchanged and 2 are worse. Eight patients are dead and nine are lost to follow-up. Ductal anatomy is the most important consideration in the selection of a procedure. Lateral pancraticojejunostomy, when applicable, is the procedure of choice. Resection should be considered when pancreaticojejunostomy has failed or is not indicated with pancreaticoduodenectomy, the procedure of choice in the diffusely diseased gland. Sphincteroplasty should be reserved for use in stenosing papillitis or as an ancillary procedure. Splanchnicectomy can be used for temporary palliation.     

The current role of thymectomy for myasthenia gravis

Myasthenia gravis is an autoimmune disease characterized by muscle weakness and fatigability due to a reduction in available acetylcholine receptors at the neuromuscular junction. Treatment with anticholinesterase drugs and corticosteroids has improved the prognosis for patients with this disease. However, controversy continues concerning the indications for thymectomy. During a 9 year period, 27 patients who underwent thymectomy by median sternotomy were reviewed. Eighty-one percent of these patients benefited from the procedure. Clinical improvement did not correlate with age, sex, duration of symptoms, severity of disease or thymic histology. This suggests that the indications for thymectomy should be liberalized to include most patients with generalized myasthenia who fail to respond readily to conventional medical therapy. The importance of immunosuppression and plasmapheresis in the therapy of myasthenia gravis awaits further delineation of the immune defect associated with the disease.     

Percutaneous placement of Hickman catheters for prolonged venous access

The Hickman catheter is well established as a safe, reliable means of venous access in a variety of clinical situations. Although the technique for placement by surgical cutdown in the cephalic or external jugular vein is standardized, our experience placing 102 catheters in the last 40 months has led us to evolve and adopt a percutaneous method that we have now applied to almost all catheter placements. Operative time has been dramatially reduced, patient discomfort minimized, and no change in short- or long-term morbidity has been noted. The procedure has been described in detail, and our overall experience with placement of the Hickman catheter in a variety of clinical situations has been reviewed. We now consider this percutaneous technique to be the primary method of Hickman catheter placement unless specifically contraindicated.     

The role of biofeedback and relaxation therapy in arterial occlusive disease

Eleven patients with chronic arterial occlusive disease and intermittent claudication were treated with biofeedback-relaxation therapy in an attempt to increase walking time by improving peripheral blood flow. Criteria for admission to the study included (1) participation in an exercise program without improvement in symptoms (2) a maximal treadmill walking time (MWT) of <5 min and (3) an ankle blood pressure of <60 mm Hg immediately postexercise. Patients were randomized into two groups: Group I entered biofeedback training immediately, and Group II served as controls for 3 months prior to undergoing the same treatment protocol as Group I. Patients were taught EMG and skin temperature feedback during 30 1-h training sessions over a 13-week period. Following biofeedback therapy all patients in Group I significantly increased their MWT (P < 0.001) while patients in the control Group (II) showed minimal improvement in MWT. After undergoing biofeedback therapy, Group II also improved their MWT. At the completion of the study, 9 of 11 patients walked >8 min. The improved MWT was associated with a fall in resting (P < 0.05) and exercise (P < 0.01) arm systolic blood pressure. Both the exercise ankle blood pressure (P < 0.05) and exercise ankle/arm blood pressure ratio (P < 0.01) increased significantly following biofeedback therapy, suggesting a reduction in resistance around the site of occlusion. Our findings indicate that biofeedback training may be an effective nonoperative treatment for selected patients with arterial occlusive disease and intermittent claudication.     

Early surgical decompression in the management of electrical injuries

Eighty patients with electrical injuries admitted to the University of Utah Intermountain Burn Center in the last 5.5 years were reviewed. Early surgical decompression with fasciotomy and sequential wound debridement appear to result in a low amputation rate and conservation of limb length. The technetium-99m pyrophosphate scan is the most helpful adjunctive method to locate hidden areas of muscle damage.     

Intramuscular pressure in the burned arm: measurement and response to escharotomy

Using a wick catheter technique, sequential measurements of intramuscular pressure were obtained in 31 burned arms in 18 patients. Abnormally high pressures were recorded in 90 percent of extremities and exceeded the potentially harmful level of 30 mm Hg in 42 percent. Correlation of intramuscular pressure with signs and symptoms of extremity compression, including Doppler pulses, was poor. Intramuscular pressure elevation appeared to parallel edema formation beneath the burn wound. A high incidence of pressure measurements in excess of 30 mm Hg was found in patients who had 30 percent or greater total body surface area injury (67 percent), 10 percent or greater full-thickness burns (75 percent), and extremities with circumferential involvement (57 percent). In every case escharotomy produced a dramatic decrease in intramuscular pressure, while a randomized group of extremities that were not decompressed developed sustained pressures as high as 64 mm Hg despite the presence of intact Doppler pulses. Extremities treated in this manner appeared slower in resolving edema and regaining motion and strength. Measurement of intramuscular pressure beneath the burn eschar is recommended in evaluating all patients at risk from extremity burns.     

Computerized tomography in the evaluation of blunt abdominal trauma

Computerized tomography has proved useful in the evaluation of selected patients suffering blunt abdominal trauma. Seventeen patients with major multisystem injuries were treated using a protocol involving abdominal computerized tomographic scans for evaluation of intraabdominal injury. Significant solid organ injury was accurately diagnosed in 10 of 17 patients, 2 of whom eventually required surgical treatment. The remainder of the patients with intraabdominal solid organ injury diagnosed by computerized tomographic scan were followed under strict guidelines and recovered without surgery. Computerized tomography represents a quick, accurate diagnostic technique for dealing with blunt abdominal trauma in selected multiply injured patients.     

Major surgery in leukemia

Complications of leukemia that required surgery in twenty-five patients over a five year interval were reviewed. Sixteen patients with chronic leukemia underwent a total of twenty-one operations with one operative death. Nine patients with acute leukemia required ten operations, with two operative deaths. These patients tend to have specific types of complications that are particular to leukemic patients, and with proper support the majority of these patients can be benefited.     

Management of tar and asphalt injuries

Tar and asphalt burns are unique injuries because the chemical is difficult to remove without inflicting further tissue injury. Since 1978, 42 patients have been treated for hot tar or asphalt injuries, 30 of whom required hospitalization. Inpatients were all male with a mean age of 27.2 years and a mean burn size of 9.3 percent total body surface area (mean full-thickness injury 5.3 percent total body surface area). Burns of critical areas were present in 63.3 percent of the inpatients. A petroleum-based, surface-active solvent was used to remove the tar or asphalt. This solvent proved nonirritating and removed tar much faster than other agents. Early excisional therapy was performed in 63.4 percent of the patients, 80 percent of whom returned to work within 6 weeks of injury. Principles of management include rapid cooling of tar or asphalt to solidify the inciting agent and dissipate heat; removal with a new, nontoxic solvent; early excision and grafting of appropriate injuries; and an aggressive, early back-to-work philosophy.     

Computed tomography in the evaluation of abdominal abscesses

Review of experience using computed tomography in 50 patients with a suspected diagnosis of abscess indicated it to be accurate and reliable. Most abscesses were sharply demarcated masses. After intravenous injection of contrast medium, the rim was enhanced in about 35 percent of the patients. In six patients the inflammatory mass had ill-defined borders. It is concluded that when the computed tomographic findings are correlated with clinical history, the correct diagnosis can almost always be reached. If surgery is not contemplated, computed tomography or ultrasound-guided needle aspiration should be performed to confirm the diagnosis.     

Lasers in endoscopic gastrointestinal surgery

Lasers have been used for endoscopic gastrointestinal surgery at our institution since 1977. The argon and Nd-YAG lasers are valuable for coagulating upper gastrointestinal hemorrhage, arteriovenous malformations, and benign and malignant lesions, as well as a variety of anatomic anomalies. Between December 1977 and September 1983, 222 procedures were performed in 122 patients. Hospital charts were reviewed and a scale constructed to assess the results of treatment. When information was available, a comparison of transfusion requirements before and after laser therapy was made. Success was achieved in 84 percent of the patients regardless of initial diagnosis. Laser therapy was not effective in 12 patients (10 percent). In 27 patients with gastrointestinal atrioventricular malformations, transfusion requirements fell from a mean of 17 +/- 5.9 units in the year before laser therapy to 1 +/- 0.8 units in the year after laser phototherapy (p less than 0.01). Complications rarely occurred (6 percent of all procedures). There were no perforations of the gastrointestinal tract and only one death (0.8 percent) partially attributable to laser application. Endoscopic laser surgery is minimally invasive and can be performed on an outpatient basis without anesthesia. It is especially valuable in patients with a high operative risk.     

Jaundice in patients with acute cholecystitis: Its validity as an indication for common bile duct exploration

Our study demonstrates that (1) mild to moderate jaundice is frequently seen in patients with acute cholecystitis; (2) severe degrees of jaundice were seen in two patients without the presence of common duct stone or recognizable obstruction of the common bile duct; (3) only one of forty-one patients with acute cholecystitis had common bile duct stone; (4) jaundice does not appear to be a compelling reason for choledochotomy; and (5) less invasive technics such as intravenous and intraoperative cholangiography should suffice to exclude the possibility of common bile duct stone in patients with acute cholecystitis.     

Acute renal failure after abdominal surgery. The importance of sepsis

Twenty-six patients with acute renal failure associated with intra-abdominal disease were evaluated for the cause of renal failure. Sepsis accounted for renal failure in fourteen of the patients. Fifty per cent of the patients died and death was due to sepsis in 62 per cent.     

Sepsis in the management of complicated biliary disorders

Postoperative sepsis developed in 72 per cent of 25 patients with noncalculous proximal biliary tract obstruction. Six episodes of shock and one death resulted. Twenty-eight per cent of septic events occurred despite the administration of prophylactic antibiotics. The incidence of septic complications was similar regardless of the biliary drainage procedure used. Despite the advent of broad spectrum antibiotics and improved surgical techniques for biliary decompression, sepsis remains a serious and frequent complication in patients with chronic bile duct obstruction.     

Effects of parenteral alimentation on postoperative gastric function

The effects of parenteral hyperalimentation on postoperative gastric function were studied in eleven patients undergoing abdominal aortic surgery. Positive nitrogen balance was achieved in hyperalimented patients. Hyperalimentation was found to augment gastric mucosal regeneration, allowing for more physiologic secretory patterns and the maintenance of the protective gastric mucosal mechanism.