The value of the medical examiner as a member of the multidisciplinary trauma morbidity-mortality committee

The multidisciplinary trauma peer review process collects, reviews, discusses, and collates all morbidities and mortalities of injured patients to institute corrective action in a timely manner. The resultant remedial activity may include professional education, physician counseling, restriction of privileges, or changes in the trauma care system. Effective corrective action necessitates timely data input from the postmortem examination. Faced with an inordinate delay, skimpy reports, and expense in obtaining such reports from the medical examiner's office, the chief medical examiner was invited to become a member of the peer review committee. During a 12-month interval as a full-fledged member of the peer review process, the medical examiner was able to provide complete verbal reports on all deaths resulting in a synergistic benefit to the peer review process and to the medical examiner office. Two of 53 nonpreventable deaths were reclassified as possibly preventable in one and preventable in the other. Four of 15 possibly preventable deaths were reclassified based on the medical examiner report. In turn, the physician members of the team were able to augment the medical examiner's knowledge in certain areas that were critical for his analysis of accidents or homicide. Based on these findings, the medical examiner is recommended as a participating member of the trauma peer review committee.

Prediction of rib fracture injury outcome by an artificial neural network

Outcome-based therapy is becoming the standard for assessing patient care efficacy. This study examines the ability of an artificial neural network to predict rib fracture injury outcome based on 20 intake variables determined within 1 hour of admission. The data base contained 580 patient records with four outcome variables: Length of hospital stay (LOS), ICU days, Lived, and Died. A 522-patient training set and a 58-patient test set were randomly selected. Nine networks were set up in a feed-forward, back-propagating design with each trained under different initial conditions. These networks predicted the test set outcome variables with an accuracy as high as 98% at the 80% testing level. Internal weight matrix examination indicated that age, ventilatory support, and high trauma scores were strongly associated with both ICU days and mortality. Being female, injury severity, and injury type were associated with increased LOS. Smoking and rib fracture number were low-level predictors of the four outcome variables.

Retrograde gastroesophageal intussusception complicating chronic achalasia

We treated a patient with retrograde gastroesophageal intussusception complicating chronic achalasia. Operation consisted of diaphragmatic division in the median plane to facilitate reduction, followed by Heller myotomy and fundoplication for the achalasia. The patient was able to eat normally after recovery.

Importance of lipooligosaccharide structure in determining gonococcal resistance to hydrophobic antimicrobial agents resulting from the mtr efflux system

Levels of gonococcal resistance to antimicrobial hydrophobic agents (HAs) are controlled by the mtr (multiple transferrable resistance) system, composed of the mtrRCDE genes. The mtrR gene encodes a transcriptional repressor that appears to regulate expression of the upstream and divergent mtrCDE operon. The mtrCDE genes encode membrane proteins analogous to the MexABOprK proteins of Pseudomonas aeruginosa that mediate export of structurally diverse antimicrobial agents. In this study we found that a single base pair deletion in a 13 bp inverted repeat sequence within the mtrR promoter resulted in increased resistance of gonococci to both crystal violet (CV) and erythromycin (ERY) as well as to the more lipophilic non-ionic detergent Triton X-100 (TX-100). However, this cross-resistance was contingent on the production of a full-length lipooligosaccharide (LOS) by the recipient strain used in transformation experiments. Introduction of this mutation (mtrR-171) into three chemically distinct deep-rough LOS mutants by transformation resulted in a fourfold increase in resistance to TX-100 compared with a 160-fold increase in an isogenic strain producing a full-length LOS. However, both wild-type and deep-rough LOS strains exhibited an eightfold increase in resistance to CV and ERY as a result of the mtrR-171 mutation. This suggests that gonococci have different LOS structural requirements for mtr-mediated resistance to HAs that differ in their lipophilic properties. Evidence is presented that gonococci exclude HAs by an energy-dependent efflux process mediated by the mtr system.

Lower esophageal sphincter dysfunction precludes safe gastric feeding after head injury

Early nutrition is advocated for patients with head injury to counter the postinjury hypermetabolic state. The gastric route of feeding often leads to vomiting and aspiration pneumonitis. This study was designed to identify the role of lower esophageal sphincter (LES) function in this complication. The LES function was assessed within 72 hours of admission in 16 patients with a head injury and a Glasgow Coma Scale (GCS) score less than 12 (range, 3-11). Other admission assessments included an APACHE II score of 11.7, Injury Severity Score (ISS) of 30.5, and a Revised Trauma Score (RTS) of 6.4. These studies were repeated 1 week postinjury in five patients. Dysfunction of the LES was present in all 16 patients; the average gastric-to-esophageal pressure difference was -0.49 mm Hg (range, -0.59 to 2.5) compared with a normal value of greater than 20 mm Hg. The five patients restudied at 1 week had a gastric-to-esophageal pressure difference of 13.3 mm Hg (range, -3.4 to 36.6 mm Hg). The single patient with a GCS score below 12 at 1 week had a low LES tone. These data show that LES dysfunction accompanies acute head injury and contributes to aspiration pneumonitis after early gastric feeding. Nutrition in patients with low GCS scores should be parenteral or via the jejunum.

Massive steroids do not reduce the zone of injury after penetrating spinal cord injury

The National Acute Spinal Cord Injury Study II concluded in 1990 that high-dose methylprednisolone (MP) improved neurologic recovery after acute spinal cord injury (ASCI). We tested this conclusion by analysis of 54 patients with ASCI; 25 patients were treated without MP before 1990 whereas 29 patients were treated with MP after 1990. Neurologic deficit was assessed regularly, in most cases daily. Motor and sensory scores on admission, and best results at one-half week (days 2 to 4), 1 week (days 6 to 10), 2 weeks (days 11 to 21), 1 month, and 2 months were noted for both groups. Motor assessment was recorded in 22 muscle segments on a scale of 0 (complete deficit) to 5 (normal); the range, thus, was 0 to 110. The 23 patients with closed injuries demonstrated no difference in improvement with or without MP. In contrast, MP was associated with impaired improvement in the patients with penetrating wounds; the 15 patients with no MP therapy had an admission motor score of 49, which increased by 6.9 at one-half week, whereas the 16 patients treated with MP had an admission motor score of 48, which decreased by 0.3 at one-half week (p = 0.03). The neural status seen by day 4 persisted throughout the next 2 months. Changes in sensation paralleled the changes in motor function. We conclude that MP therapy for penetrating ASCI may impair recovery of neurologic function.

Splenic reimplantation does not affect outcome in chronic canine model

The effects of septic insult were compared in a canine model of splenic reimplantation. Sequential changes in hematologic, hepatic, and immunologic function were monitored biweekly in 18 dogs during 10 months after splenectomy, splenectomy with reimplantation, or sham operation. There was no significant difference in these measures between the two groups. At the end of the 10-month period, spleen scans with technetium (99Tc) labeled, heat-damaged RBCs were obtained on the reimplanted dogs. 99Tc scanning revealed no active splenic implants at 10 months. All dogs were then infected with intravenous Type III pneumococcus for 9 consecutive days. There were no measurable hematologic, hepatic, or immunologic differences between groups before or after the septic insult. These animals were then sacrificed for histologic analysis of the splenic reimplants. Reimplant histology showed active germinal centers, but the surrounding pulp was fibrotic and lymphocyte-depleted. Splenic reimplantation in this canine model yields no apparent benefit.

Antrectomy. A safe and effective bypass for unresectable pancreatic cancer

BACKGROUND

Pancreatic cancer is most often diagnosed too late for curative resection. Operative therapy, therefore, involves relief of biliary obstruction and relief or prevention of gastric outlet obstruction. Previous studies show that gastrojejunostomy done either therapeutically or prophylactically often causes delayed gastric emptying.

OBJECTIVE

To describe the results of antrectomy with Billroth II reconstruction (A/BII) as the palliative operation for gastric outlet obstruction.

SUBJECTS

Fifty patients with unresectable pancreatic cancer underwent A/BII without vagotomy from 1987 through 1993. Of these patients, 42 underwent simultaneous biliary bypass; six had undergone biliary bypass from 3 weeks to 34 months previously; and two with cancer originating in the uncinate process had no biliary bypass.

RESULTS

One 87-year-old patient died on day 12 of azotemia and pulmonary insufficiency. The other 49 patients were discharged tolerating an oral diet an average of 11.3 days (range, 5 to 29 days) after A/BII. The length of stay following A/BII was not related to the extent of disease or to preoperative weight loss but was increased in older patients.

CONCLUSION

The A/BII is a safe and effective bypass in patients with unresectable pancreatic cancer.

Regionalization of critical care medicine: task force report of the American College of Critical Care Medicine

OBJECTIVES

To review the existing literature and task force opinions on regionalization of critical care services, and to synthesize a judgement on possible costs, benefits, disadvantages, and strategies.

DATA SOURCES

Pertinent literature in the English language.

STUDY SELECTION

One hundred forty-six English language papers were studied to determine possible ramifications of regionalization of critical care or other similar services.

DATA EXTRACTION

Information on possible influence on the care of the critically ill was sought and integrated with the opinions of task force members. Possible costs, benefits, as well as disadvantages to the patient, transferring and receiving institutions, and region as a whole were sought.

DATA SYNTHESIS

Regionalization of critical care services was thought to be advantageous to the patient. The larger academic institutions tend to have more resources, better subspecialty availability, and expertise in the care of the critically ill. Efficiency and safety during transport need to be in place. Disadvantages of overutilization, possible costliness to both the referring institution as well as to the receiving institution were outlined. It was agreed that pediatric critical care medicine was a separate issue.

CONCLUSIONS

Regionalization of critical care medicine probably is beneficial and the concept should be explored.

Duodenal organ injury severity (OIS) and outcome

The effect of organ injury severity on outcome was assessed in 101 patients treated for duodenal trauma. Most patients were men (89%) and victims of penetrating wounds (93%). Grade I is minor hematoma or incomplete perforation; Grade II is major hematoma or small complete perforation; Grade III is large perforation excluding ampulla; Grade IV is large perforation at ampulla; Grade V is duodenopancreatic crunch. The injuries were as follows: Grade I (5 patients), Grade II (31), Grade III (40), Grade IV (12), and Grade V (13). Fourteen patients exsanguinated from associated vessel injury; each had Grade IV or Grade V injury. All 36 patients with Grade I and Grade II injury had primary repair; the single death was due to liver necrosis. Most (31 patients) Grade III injuries and three Grade IV injuries were treated by primary repair alone; the three deaths were unrelated to the duodenal injury. Other major injuries were treated by duodenal exclusion (4 patients), duodenal diverticulization (6), or resection (4); the single death was unrelated to the duodenum. Primary closure is favored for minor injuries and most Grade III injuries. Severe injuries may require exclusion, diverticulization, or resection.

The technique of visceral packing: recommended management of difficult fascial closure in trauma patients

Since 1986, we have cared for 17 patients whose abdomen could not be closed because of bowel edema and loss of abdominal wall compliance. These patients were managed by a technique of visceral packing with the intestines kept in place by a combination of rayon cloth, gauze packs, and retention sutures. This packing was changed in the operating room under general anesthesia until the edema was sufficiently resolved to allow for closure. Two patients died within 24 hours of operation from irreversible shock. The remaining 15 patients had their fascia successfully closed with an average of two additional anesthetics. There was one case of fasciitis associated with the development of an intra-abdominal abscess and one patient died of late sepsis. There was no early postoperative ventilatory compromise or acute oliguric renal failure. Other direct complications have been minor with no enterocutaneous fistulae, dehiscence, or incisional hernia. Visceral packing of posttraumatic abdominal wounds circumvents expected complications of intraperitoneal hypertension and enhances the chance for survival. Its ease and low morbidity also lends itself to a wide variety of other uses.

The vascular-interstitial pH gradient during and after hemorrhagic shock

The interstitial fluid space (IFS) response to hemorrhagic shock (HS)-induced metabolic acidosis is reported. Prenodal skin lymph was used as a mirror of IFS changes. Twenty-three conditioned dogs had a reservoir HS insult followed by resuscitation with shed blood, crystalloid solution containing a total of 6.5 milliequivalents of sodium per kilogram of body weight and 250 milliliters of autologous banked blood. Prenodal skin lymph pH, oxygen tension (pO2), carbon dioxide tension (pCO2), bicarbonate level (HCO3) and flow rate measured before shock, during HS and in postresuscitation in 17 dogs in group 1 were compared with simultaneous samples of central venous blood. Peripheral venous values were not measured in dogs in group 1 to preclude any effects that local dissection might have on prenodal skin lymph. Six dogs in group 2 underwent the same HS and resuscitation model; the sequential changes in central mixed venous pH and lymphatic pH were compared with peripheral venous pH. HS caused metabolic acidosis; in group 1, the mixed venous pH decreased to 7.16 and in group 2, the peripheral venous pH decreased to 7.03. In contrast, the prenodal skin lymph pH in both groups was maintained at PS levels (7.51). Mixed venous pO2 decreased sharply with HS, whereas skin lymph pO2 was maintained. Maintained prenodal skin lymph pH and pO2 during HS-induced metabolic acidosis implies that the IFS undergoes stoichiometric changes. This facilitates the preferential adherence of highly charged proteins, like albumin, to the matrix to maintain cellular homeostasis.

Delayed pneumothorax after central venous access: a potential hazard

Percutaneous central venous catheter access is common-place in surgical patients. Though several major complications of this procedure have been described, pneumothorax is the most common. Pneumothorax is routinely assessed by a chest X-ray within 2 hours after catheter placement. During a recent 6-month interval, the authors identified five patients with delayed onset and diagnosis of pneumothorax following percutaneous central venous access. All immediate post-insertion chest X-rays were normal; however, subsequent chest X-ray showed evidence of pneumothoraxes. The pneumothorax contributed to the death of one patient on positive pressure ventilation. A review of the literature revealed a total of 18 patients in the English literature with this complication. Although the incidence of delayed pneumothorax is low, it is, in some instances, life threatening, particularly in patients on positive pressure ventilation. A high index of suspicion is required to diagnosis and treat this reversible condition.

Management of the difficult abdominal closure

Hemorrhagic shock and multiple trunk injuries, especially severe pelvic fracture, may cause massive swelling of intra-abdominal viscera and the abdominal wall, thereby precluding safe, primary abdominal wall closure. Primary closure, under tension in such patients, causes a multitude of problems including respiratory compromise, reduced cardiac output, oliguria, enterocutaneous fistulae, impaired abdominal wall nutrient blood supply, necrotizing fasciitis, evisceration, and death of the patient. Multiple methods have been described to aid the surgeon in circumventing these problems. The authors advocate the abdominal wall pack technique, which has the advantages of ease of implementation and a low rate of wound complications.

A comparison of the gastric bypass and the gastric wrap for morbid obesity

The standard for surgical treatment of morbid obesity is gastric reservoir reduction (GRR). The two popular techniques for GRR are the gastric bypass (GBP) and vertical banded gastroplasty. In 1981, a new approach to GRR, namely, the gastric wrap (GW) was introduced. The GW envelops the stomach in a customized Teflon (polytetrafluoroethylene) mesh. The current study compares, for the first time, the long term efficacy of GW and GBP. One hundred and five morbidly obese patients were studied. Fifty-two patients had GBP and 53 had GW. Preoperative and ideal weights averaged 301 and 129 pounds in the GW patients versus 278 and 123 pounds in the GBP patients. The two groups had similar age, height and co-morbid conditions. All patients survived the operation. After discharge, the patients had follow-up examinations at two weeks, two months, six months and then yearly. The GW was significantly more effective than the GBP in attaining and maintaining weight loss. The increased percent excess weight loss (percent EWL) was statistically significant at 12 months when the GW patients achieved 67 percent EWL compared with 57 percent EWL in the GBP patients. After the third year, the percent of EWL declined in the GBP patients, averaging 48 percent at four years and 47 percent at five years. In contrast, the GW patients maintained a 72 percent EWL at four years and a 66 percent EWL at five years. This weight loss was accomplished without nutritional embarrassment in both groups. The superiority of the GW in achieving and maintaining weight loss is reflected by the opinions of the patients regarding the attainment of preoperative objectives and their willingness to recommend GW to others. The downside of the GW is the higher incidence of reversal and the increased technical difficulties with reversal or revision compared with the GBP.

Triiodothyronine (T3) improves cardiovascular function during hemorrhagic shock

Prior work showed that an intact thyroid axis augments survival from hemorrhagic shock (HS); this study assesses the effects of specific thyroid-related hormones on cardiovascular (CV) function during HS. Following thyroidectomy, 32 conditioned male dogs were subjected to HS to a mean arterial pressure (MAP) of 60 mm Hg for 90 min then to 40 mm Hg for 30 min. Postshock (PS), the dogs received thyroid-releasing hormone (TRH; 2 mg/kg), thyroid-stimulating hormone [control (TSH; 10 IU)], T3 (12 micrograms/kg), or T4 (40 micrograms/kg). Thirty minutes following treatment (PTX), they were resuscitated with shed blood and 50 ml/kg saline. CV and hormonal parameters were measured PS, PTX, postresuscitation (PR), and on day 2 (D2). There were no PS differences in CV parameters between groups. Following treatment, T3 significantly increased MAP (59.0 +/- 13 vs, 39.9 +/- 2.2 mm Hg) and cardiac output (CO; 0.92 +/- 0.1 vs. 0.80 +/- 0.1 liter/min; P < 0.05 by ANOVA). TRH treatment significantly improved PTX MAP (62.7 +/- 10 vs. 40.8 +/- 2.1; P < 0.05 by ANOVA). TSH and T4 did not significantly change PTX MAP or CO. There were no significant CV differences in the four groups following resuscitation or on D2. In conclusion, T3 improves MAP and CO during hemorrhagic shock. TRH transiently improved PTX blood pressure. Further study of the mechanism of this beneficial response afforded by T3 administration is warranted.

Splenic abscess associated with endocarditis

BACKGROUND

Refractory or recurrent sepsis in patients with endocarditis may be from splenic abscess. The purpose of this review is to assess this relationship.

METHODS

Of 564 patients treated for documented endocarditis between 1970 and 1990, splenic abscesses developed in 27 patients. The mean age of the 18 men and nine women was 37 years. Etiologic factors included street drugs, dental abscess, and rheumatic fever. Symptoms included fever, myalgia, chills, and dyspnea; the prodrome averaged 2 weeks. Typical signs were heart murmur, left lower-lobe infiltrate, and leukocytosis. Splenomegaly was found in three patients. All patients had valve lesions, which involved the aortic valve alone in 10 patients, the mitral valve alone in eight patients, and multiple valves in nine patients.

RESULTS

A splenic defect on computed axial tomographic scan was diagnosed correctly as an abscess in 10 patients, was indeterminant in three patients, and was incorrectly called an infarct in four patients. Thirteen patients died. All 10 patients treated without splenectomy died, including five patients who underwent valvular replacement. In contrast, only three of 17 patients treated by splenectomy with (11 patients) or without (six patients) valvular surgery died.

CONCLUSIONS

Splenic abscess often accompanies endocarditis. The diagnosis is suspected by refractory fever and confirmed by abdominal computed axial tomography scan. Splenectomy is warranted before or after valvular surgery, depending on the patient's clinical response to antibiotics.

The influence of an anesthetic regimen on patient care, outcome, and hospital charges

The effects of the anesthetic regimen on patient care, outcome, and hospital charges were studied in 86 morbidly obese patients who underwent gastric reservoir reduction at two hospitals (A and B) in the Detroit Medical Center. At Hospital A, postoperative ventilation was routinely planned in 36 patients who received two intravenous lines, an arterial ine, and a Foley catheter. At Hospital B, postoperative ventilation was not routinely planned for in 50 patients who received one intravenous line and no Foley catheter or arterial line. For anesthesia, Hospital A routinely used isoflurane (0.98%) and N2O (53.0%) with little fentanyl (0.7 mg in 26 patients). Muscle relaxation with pancuronium (13.2 mg) was reversed in only five patients. In contrast, Hospital B patients used little isoflurane (0.4% in 14 patients),* more N2O (64.0%),* more fentanyl (1.3 mg),* and less pancuronium (9.7 mg)*; reversal with naloxone and pyridostigmine was routine. The operating room time was longer in Hospital A patients (5.0 vs 4.6 hours),* and they received significantly more intravenous fluids (6.2L vs 3.2L).* Routine postoperative ventilation in Hospital A patients led to a 46.5 hour intensive care unit stay and a 9.7 day postoperative stay. In contrast, routine anesthetic reversal allowed operating room extubation, patient self-transfer to the stretcher, and ambulation on the day of surgery in Hospital B where patients had a 1.7 hour recovery room stay and a 9.6 day postoperative stay. Total hospital charges in Hospital A patients averaged $14,524.00 due to the increased cost of the intensive care unit ($2,094.00) and support services versus $7,580.00* in Hospital B patients. All 86 patients survived.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison of gastrostomy techniques in patients with advanced head and neck cancer

Patients with advanced head and neck carcinomas often suffer from impaired deglutition and require prolonged enteral feedings during therapy. This retrospective study analyzed 75 patients managed with three different gastrostomy techniques. Thirty patients received a percutaneous endoscopic gastrostomy; 28 patients had an open tube gastrostomy using a Foley or Malecot catheter through a purse-string stay suture; and 17 patients received an open-tube gastrostomy with a 1-cm Dacron-cuffed Silastic catheter enclosed in a 3-cm Witzel tunnel with the cuff buried in the subperitoneal pocket. The complication rate for 100 days of tube use was 0.21 for cuffed Silastic gastrostomy, 0.35 for open tube gastrostomy, and 1.41 for the percutaneous endoscopic gastrostomy group. We conclude that the cuffed Silastic gastrostomy technique is superior in this patient population.

Antrectomy with gastrojejunostomy for unresectable pancreatic cancer-causing duodenal obstruction

The traditional approach to gastric outlet obstruction caused by unresectable pancreatic cancer is gastrojejunostomy performed during or after biliary bypass surgery. Previous work showed that gastrojejunostomy failed in 95% of patients with preoperative outlet obstruction, which was evidenced by nausea and vomiting. This study defines a better bypass procedure, namely, antrectomy with gastrojejunostomy, which was performed in 19 such patients. The cancer was primary pancreatic in 17 patients and metastatic to the pancreas in two patients with a renal and urinary bladder primary. All patients had duodenal extension with impaired alimentation. Fourteen patients underwent simultaneous biliary bypass surgery and antrectomy with gastrojejunostomy; the antrectomy with gastrojejunostomy procedure was performed in five patients 3 weeks to 6 months after biliary bypass surgery when duodenal obstruction supervened. Visible cancer extended to the duodenal stump in five patients, including two patients whose partial closure was buttressed with omentum. All 19 patients tolerated regular diet at the time of discharge 1 to 4 weeks after the antrectomy with gastrojejunostomy procedure. All patients, who died at 4 to 21 months after surgery tolerated solid food until immediately before death. All nine surviving patients have taken solid foods 9 to 29 months since the antrectomy with gastrojejunostomy procedure. We conclude that the antrectomy with gastrojejunostomy procedure, whether performed simultaneously with or subsequently to biliary bypass surgery, is the best palliative procedure for duodenal obstruction in patients with unresectable pancreatic cancer.

Colloid oncotic pressure and body water dynamics in septic and injured patients

Colloid oncotic pressure (COP) and fluid shifts were studied in 43 septic (SS) patients and 33 injured (HS) patients (ISS = 48.2). During maximal postresuscitation fluid retention, plasma volume (PV/RISA), red cell volume (RBC/51Cr), inulin space (ECF), and COP were measured. Interstitial space (IFS), PV/IFS ratio, and correlation coefficients (r) were calculated. A subgroup of 22 SS patients and 22 HS patients of equal study weight were also compared. Septic patients had greater IFS expansion (17.6 L vs. 11.5 L) than HS patients who, by inference, had more intracellular expansion. Expansion of IFS in SS patients correlated (r = -0.76, p less than 0.02) with reduced plasma COP; this was not seen in HS patients (r = -0.09, p less than 0.35). In contrast, plasma COP correlated (r = 0.72, p less than 0.001) with PV/RISA in HS patients but not in SS patients (r = 0.09, p greater than 0.35). We conclude: (1) SS patients with greater IFS expansion that correlates with reduced plasma COP likely have increased capillary permeability; and (2) HS patients with less IFS expansion that does not correlate with reduced plasma COP likely have maintained capillary permeability with altered IFS matrix configuration causing reduced protein exclusion.

Recurrent spontaneous intrahepatic hemorrhage from peliosis hepatis

Peliosis hepatis is a rare and highly lethal liver lesion in which numerous blood-filled cavities or cystic spaces are dispersed throughout the hepatic parenchyma. The cause is unknown, although the condition is associated with several disease states and medications. Patients may present with hemorrhage, liver failure, the hepatorenal syndrome, cholestasis, or portal hypertension. We treated a patient who survived two separate hemorrhages from peliosis hepatis. The surgical intervention used, hepatic dearterialization, has allowed this patient to remain asymptomatic for 5 years.

Effect of hemostatic agents in canine gastric serosal blood vessels

The efficacy of various sclerotherapeutic agents in the control of acute bleeding, via subserosal injection, was assessed in 10 dogs. Blood flow rate (BFR) from severed gastric serosal vessels (diameter, 1.6 to 2.2 mm) was measured for 3 min (ml/min) for a control group and the agent used. The agents tested were 5 ml of normal saline (NS), 5 ml of 3% hypertonic saline (HS), 5 ml of 1:10,000 epinephrine in NS, 5 ml of 1:10,000 epinephrine/HS, 5 ml of 1:20,000 epinephrine/HS, 2 ml of old thrombin "cocktail" (thrombin, cephapirin + 1% tetradecyl), and 2 ml of fresh thrombin cocktail (total seven). One agent was tested per dog; there were one to two dogs in each subgroup. All of the agents showed significant reduction in BFR (except old thrombin) when compared with BFR of control vessels. The reduction ranged from 30% to more than 75% after 1:10 epinephrine/HS. Complete hemostasis was achieved in up to 47% of vessels using 1:20 epinephrine/HS. Overall, the epinephrine solutions achieved the best results. No systemic effects were observed with the use of any of the agents. Histological studies showed that epinephrine caused mild tissue damage, whereas the cocktail caused significant tissue necrosis. This serosal vessel model permits comparison of the effectiveness of each agent; however, clinical extrapolation to mucosal vessels in a patient and the long-term histological changes are not known.

Sclerotherapy of bleeding esophageal varices using a thrombogenic cocktail

The short- and long-term efficacy of a thrombogenic sclerosant (1% tetradecyl sulfate, thrombin, and cefazolin) was studied in 101 patients. The majority of patients had alcoholic cirrhosis with Child's C classification (84/101). Bleeding was controlled in 94 per cent of patients with the first sclerotherapy. In-hospital and early (within 6 weeks) mortality were 14 per cent and 19 per cent, respectively. There was a strong correlation with hospital mortality and the severity of hepatic disease. Long-term follow-up in 70 patients (mean of 16 months) showed that survival correlated with compliance to follow-up sclerotherapy and abstention from further alcohol intake. Mortality in patients compliant with follow-up was 5 per cent (1/19), as compared with 24 per cent (12/51) in patients who were not compliant with follow-up sclerotherapy. The mortality in alcoholic cirrhotic patients who abstained from further alcoholic intake was 6 per cent (1/17), as compared with 23 per cent (10/44) in those who continued to abuse alcohol. No systemic thrombotic or allergic events related to the use of bovine thrombin were noted during a total of 349 sclerotherapy sessions.