Spontaneous rupture of the common bile duct

Spontaneous rupture of the common bile duct is rare, but may result from increased intraductal pressure with associated calculous erosion and necrosis of the bile duct wall secondary to thrombosis. Two cases are reported; one clearly related to calculous erosion and the other unexplained. Survival depends on early diagnosis. Aggressive supportive therapy, including Swan-Ganz catheter, intensive care unit monitoring, and appropriate antibiotics, are mandatory. Only with early operation to alleviate sepsis and decompression of the biliary system can better survival be expected.

Prevention of post-operative complications in the lower-extremity amputee

Eighty lower-extremity amputation patients were randomly divided into two groups: one that ambulated (A) early (48 to 72 hours) and one that did not (NA). Group A patients used an immediate, post-operative, pneumatic splinting device. The two groups were compared as to the incidence of wound and constitutional post-operative complications, with the A group showing significantly fewer. As in previous studies, the A group continued toward quicker and more successful rehabilitation.

An improved modality in lower extremity amputee rehabilitation

Early rehabilitation of the lower extremity amputee has been achieved in 150 men and women with an average age of 63.2 years. Diabetes was present in 47 patients; all were smokers; 108 had associated cardiovascular disease; 32 had pulmonary disease. Ambulation began at 48 hours with a pneumatic externally supported device. It was total contact, equal pressure throughout (40 mmHg). There were no complications; all patients received a definitive prosthesis 21 to 93 days after amputation. The most common cause of delay in prosthetic use was financial.

Value of periangiography hydration

The value of contrast dye to the planning and evaluation of cardiovascular disease cannot be overestimated. However, adverse renal sequellae may cause the surgeon to hesitate in obtaining an arteriogram, especially in patients with compromised renal function. The purpose of this study was to evaluate the incidence of renal dysfunction in patients requiring angiography. Standard contrast angiography for cerebral or peripheral vascular disease was administered to 150 consecutive patients (89 men and 61 women), with an average age of 63.3 years (range 49 to 89 years). All patients received 100 to 150 ml of dye, with a concentration of approximately 50% iodine. Patients were hydrated with 0.5 N saline/5% dextrose, intravenously, for 8 hours before the procedure (1 to 3 ml/kg/hr). In 31 patients (11 women and 20 men) the serum BUN and/or creatinine levels were elevated (mean BUN value of 48 +/- 9 mg/dl; mean creatinine level of 2.8 +/- 0.6 mg/dl). The patients with abnormal renal function received an additional 300 to 500 ml of intravenous fluid, plus 20 to 40 mg intravenous furosemide, 1 hour before roentgenography to establish a diuresis. All patients were hydrated for 6 hours after angiography with the same solution at the same rate (1 to 3 ml/kg/hr). There were no episodes of compromised renal or cardiopulmonary dysfunction because of contrast angiography. In no patient did the BUN or creatinine level rise, nor was there evidence of acute tubular necrosis, as documented by oliguria and abnormal cells in the urine. Angiography is a safe procedure, even with patients who may have compromised renal function, if appropriate prehydration/posthydration and diuretic measures are undertaken.

Prostacyclin synthetase activity in diabetic human venous tissue

The purpose of this study was to ascertain if alterations were present in the prostacyclin synthetase (PGI2ase) activity in diabetic human venous tissue. Saphenous veins were obtained from a group of 12 patients with (HSV-D) or without (HSV-ND) diabetes who were undergoing coronary artery bypass surgery. 14C-Labeled prostaglandin endoperoxide (PGH2) was incubated for 2 minutes with venous microsomal protein. The products were separated by thin-layer chromatography and quantified by radiochromatographic scan. PGI2ase activity was determined by the formation of 6-keto-PGF1 alpha, the stable breakdown product of prostacyclin (PGI2). Results of this study indicate the following: both HSV-ND and HSV-D specimens have active PGI2ase and are capable of forming PGI2; there is no difference between PGI2ase activity in HSV-D and HSV-ND specimens; and in diabetes mellitus, any defects in PGI2 production similar to those associated with diabetes in other investigations must reside higher in the arachidonic acid cascade.

Barbiturate therapy in the postoperative endarterectomy patient with a neurologic deficit

Three patients awoke in the operating theater with a neurologic deficit after carotid endarterectomy with shunt under general anesthesia with either upper or lower extremity paralysis or both and evidence of a patent carotid artery confirmed by Doppler ultrasonography, B-mode real-time ultrasonography, or surgery. After confirmation of patency of the carotid artery, patients were anesthetized with thiopental (3 to 4 mg/kg) for 48 hours, with respiratory maintenance by ventilator. The therapeutic effect of barbiturates was monitored by prevention of spontaneous respiration without hypotension. All patients awoke approximately 36 to 48 hours after discontinuing the thiopental without the previously noted postoperative neurologic deficit or any adverse neurologic sequelae. At last follow-up more than 1 year postoperatively they were asymptomatic. Results of this study indicate that patients who undergo carotid endarterectomy and awake with a neurologic deficit and a patent operated vessel should be considered for barbiturate induced coma as a therapeutic modality.

Pulmonary surface tension after nontoxic experimental pancreatitis

Injection of saline as well as trypsin into the pancreatic duct of the rat may cause changes in the histology and surface tension of the lung, as well as histological and biochemical evidence of pancreatitis. Nontoxic chemicals also may be the source of pancreatitis and subsequent pulmonary dysfunction. In the research setting, pressure injection into the pancreatic duct may produce systemic effects.

Modulation of prostacyclin synthetase and unmasking of PGE2 isomerase in bovine coronary arterial microsomes

Prostacyclin (PGI2), a major product of prostaglandin endoperoxide (PGH2) metabolism in blood vessels, has potent vasodilator and platelet activity. Therefore, modulation of PGI2 synthetase activity is of prime physiological importance in the regulation of blood vessel function. In this study, PGI2 synthetase activity of bovine coronary arterial microsomes could be altered over a 2-3 fold range by GSH or dithiothreitol in a concentration-dependent manner and over a microsomal protein range of 10-200 micrograms. Modulation of coronary artery PGI2 synthetase activity was also seen in vessels from sheep, dog and man. These data suggest that coronary artery PGI2 synthetase activity is unusually sensitive to the redox state or sulfhydryl oxidation of the enzyme. The present data also unmask an active PGE2 isomerase, previously reported to be absent in bovine coronary arterial microsomes.

Hyperemic stress test in diagnosis of vasculogenic impotence

A hyperemic stress test was used to determine vasculogenic impotence in 100 men (50 potent, 50 impotent). Normal potent males had a resting penile:brachial index ratio of 0.75 and uniformly demonstrated a hyperemic response to the cuff occlusion stress test with a mean of 20 per cent increase in penile pressure. Penile blood pressure did not increase in impotent men, and often it decreased in response to the stress test.

Amputations after vascular trauma in civilians

In a ten-year retrospective study of 233 patients who sustained a vascular injury to an extremity, eight (3.4%) extremities were amputated. Factors that affect the incidence of amputation after peripheral vascular trauma include early operation, fasciotomy, preoperative antibiotics, appropriate vascular reconstruction with adequate tissue coverage, use of arteriography during and after reconstruction, and early reoperation for postoperative complications. Some patients benefit psychologically and physically from early definitive amputation.

Successful thrombolytic therapy for acute and chronic occlusion of polytef vascular grafts

Thrombolytic therapy for thrombosed arterial bypass grafts has received little attention in the medical literature. We carried out successful thrombolysis in occluded polytef arterial bypass grafts. A femoral-femoral artery crossover graft had been occluded 13 days, and a femoral-popliteal artery bypass graft had been occluded three months. No surgical intervention was required. Follow-up showed continued patency nine months following thrombolytic therapy. Long-term oral anticoagulation seems indicated. Also, data suggest thrombus in polytef grafts may be particularly susceptible to lyses. Thrombolytic therapy should play an increasing role in vascular surgery.

Aortic erosion by duodenal diverticulum: an unusual aortoenteric fistula

Primary aortoduodenal fistula presenting as a diverticulum of the distal duodenum with GI bleeding may be a difficult diagnostic entity with nondiagnostic endoscopy and angiography. We have described a patient in whom diagnosis was established at laparotomy, with treatment including debridement, repair, and extra-anatomic bypass.

Arterial thromboembolism and associated antithrombin III deficiency

A patient with antithrombin III (ATT) deficiency after arterial embolism manifested an increasing requirement for heparin to adjust a partial thromboplastin time. This was corrected by dramatically increasing doses of heparin and by conversion to warfarin sodium. "Heparin-resistance" should direct the physician to examine antithrombin III levels, and ATT levels should be determined as a baseline before anticoagulation therapy.

Metabolism of prostaglandins in human saphenous vein

The described methodology allows for analysis of metabolism of the prostaglandin PGH2 in subcellular fractions (microsomes) obtained from human saphenous veins. Prostacyclin (PGI2) synthetase as identified by its stable breakdown product 6-keto-PGF1a is present in human saphenous vein. Thromboxane A2 is absent. The enzymatic formation of PGE2 was demonstrated by the addition of glutathione (GSH) indicating the presence of an active PGE2 isomerase. The data suggest that the enzymatic endoperoxide-metabolizing pathways in human saphenous vein microsomes are prostacyclin synthetase and prostaglandin E isomerase. It is suggested that the ability of the vein graft to produce prostacyclin and PGE2 may contribute to short- and long-term graft patency.

Septic pelvic thrombophlebitis: an update

Septic pelvic thrombophlebitis is the result of serious pelvic infection usually following obstetric or gynecologic procedures. The management of this condition is of historical interest to the department of obstetrics and gynecology at Tulane, and therefore a retrospective case evaluation and a prospective surveillance were undertaken. This study indicates that septic pelvic thrombophlebitis is seen very rarely today. Possible reasons for the decline in the incidence of this problem and a management plan are presented. Three cases are included.

Influence of hemorrhagic pancreatitis on the lung. An ultrastructural study

The influence of hemorrhagic pancreatitis on pulmonary ultrastructure was investigated in 21 mongrel dogs. The animals were intubated but not ventilated. Pancreatitis was induced with an autologous bile-trypsin mixture. The degree of pancreatitis was confirmed clinically, chemically, and histologically. The animals were sacrificed at four time frames: zero time, one, three, and five hours after the onset of pancreatitis. There was progression, with time, of distorted pulmonary microarchitecture. Interstitial edema, including dispersion of endoplasmic reticulum, disruption of lamellar bodies, and blunting of the pseudopods in the type II pneumocyte, were noted. There was a decrease in osmiophilic content as well as loss of organization of the lamellar bodies. Since surfactant is produced and stored by the lamellar bodies in the type II pneumocyte, these data add support to the concept of pulmonary congestive atelectasis secondary to pancreatitis--related to absence of or diminished surfactant.

Improving predictive value of complementary tests in carotid artery disease

In a prospective study the accuracy of B-mode ultrasound imaging alone was compared with its use in conjunction with bidirectional Doppler ultrasound, carotid phonoangiography, and oculoplethysmography to independently assess contrast arteriograms of carotid arteries studied for presumed extracranial vascular disease. The addition of B-mode real-time imaging improved the accuracy of diagnosis by nearly 10%.

Effect of hemorrhagic shock on 5-hydroxytryptamine removal by the lung

The biogenic amine, radioactive 5-hydroxytryptamine, is removed from the blood during passage through the pulmonary vasculature. After one hour of hemorrhagic shock, the extraction rate increased from 74 to 89 per cent. One and two hours after resuscitation, the lung extracted only 30 per cent of the 5-hydroxytryptamine. The relationship between the pathophysiologic state and altered amine removal is a reflection of prolonged exposure to receptor sites or increased diffusion of serotonin across the endothelium.

Pulmonary extraction of biogenic amines during septic shock

The effect of live Escherichia coli on the pulmonary extraction of the biogenic amines 14C 5-hydroxytryptamine, (5-HT) and 3H-epinephrine was investigated. The labeled isotopes were injected into a central venous catheter and collected from an aortic catheter. One hundred per cent of the labeled epinephrine was recovered in the control and septic state. Only 32.8 +/- 3.6% SEM of the 5-hydroxytryptamine was recovered before sepsis and 42.5 +/- 4.9% SEM after sepsis. During sepsis, mean arterial pressure fell to 58 mm Hg from 121 mm Hg. Pulmonary shunt increased from .7 +/- .05 SEM to .33 +/- .09 SEM.

Brachial artery reconstruction after traumatic disruption

We describe a series of 21 cases of traumatic disruption of the brachial artery that required surgical intervention. Stab wounds were most frequent (11), followed by gunshot wounds (six) and blunt trauma (four). Ten patients had associated upper extremity injuries including bone, nerve, and vein. Arterial repair with lateral sutures could be accomplished in only one case. Segmental resection of the artery required interposition grafts using autogenous saphenous or cephalic vein in 11 patients. No synthetic graft material was used, and prophylactic antibiotics were given to all patients. All patients are without sequelae a median of 12 months after operation. Complete neurovascular evaluation, including arteriography and venography where indicated, followed by prompt repair is necessary for a successful outcome. The cephalic vein was an excellent alternative for an interposition graft in this series of patients. Primary repair of concomitant injuries, use of perioperative prophylactic antibiotics, and rigid immobilization for a short period followed by active mobilization will yield the best results.

Management of traumatic peripheral vein injuries. Primary repair or vein ligation

The management and outcome of 83 patients who had 86 venous injuries were retrospectively reviewed to identify optimal management techniques in patients with peripheral vein injuries. Venous injuries of the arms were associated with no long-term sequelae, and management with vein ligation appears safe. In patients with venous injuries of the legs, primary repair by lateral suture or primary end-to-end reanastomosis is recommended when technically easy. In patients who are unstable or in whom primary repair cannot be performed, vein ligation is recommended. Autogenous vein interposition grafting appears indicated only in the popliteal area when vein reconstitution should be aggressively sought. Vein ligation in peripheral vein injuries should be followed with aggressive postoperative management to prevent the development of distal edema. Limb elevation is effective in minimizing the development of adverse sequelae.

The role of dilantin in the prevention of pulmonary edema associated with cerebral hypoxia

Twenty-five mongrel dogs were subjected to isolated cerebral hypoxia or noncerebral systemic hypotension to create the congestive pulmonary lesions of the shock lung syndrome (SLS). Eleven of the experimental dogs were pretreated with 5, 5-diphenylhydantoin (DPH). Prophylactic DPH protects the lung from the injury that is a consequence of hypoxic cerebral perfusion in the dog, but does not afford protection from pulmonary damage caused by isolated, noncerebral systemic hypotension. DPH confers this protection on the brain; there is no evidence that DPH exerts this protective effect by an action on the pulmonary parenchyma directly or on other tissue in the body.

Leg ulcer. Conservative management or surgical treatment?

In a specific indigent socioeconomic setting, the nonsurgical management of 65 patients with chronic leg ulcers resulted in 59 cures. There were 42 patients (67%) with postphlebitic syndrome. Twenty-two patients (33%) had varicose veins (eight had postoperative vein stripping), 14 (22%) had deep-vein thrombosis, and 11 (15%) had associated neurological problems. Fifty-six patients (86%) were treated with pressure dressings that were changed once a week in an outpatient clinic, seven patients wore skintight plaster casts for variable periods of time, and two patients had split thickness skin grafts plus lumbar sympathectomies. In more than two thirds of the patients, the ulcers healed. In another 17 patients (26%), a satisfactory response to treatment was observed. In only six patients did therapy fail. Failures were attributed to the multiple medical and surgical problems of the patients or their lack of cooperation. Nonsurgical treatment of venous stasis ulcer is inexpensive and effective.

Perineal trauma and vasculogenic impotence

Twenty men were subjected to a brief period of perineal compression. Measurement of brachial, ankle and penile blood pressures revealed a reversible decrease in pressure. Penile pressure can be measured accurately. It represents an objective method of measuring vasculogenic impotence.

Operations on the colon without preoperative oral antibiotic therapy

The ideal preparation of the intestine prior to elective colonic resection has been a controversial subject. With the development of new and more effective antibiotics, many modalities of intestinal preparation preoperatively have been used in an effort to reduce the number of infectious complications. Mechanical cleansing of the intestine, when accompanied by perioperative parenteral antibiotics, is adequate preparation prior to resection of the intestine. One hundred consecutive operations upon the colon by one surgeon were the subject of this retrospective study. Approximately 70 per cent of the operations were for carcinoma and the remainder for inflammatory disease. Preparation consisted of the administration of cathartics and saline solution enemas combined with a liquid diet for 48 hours prior to operation. Perioperative parenteral antibiotic therapy was given for 48 to 72 hours or as long as intravenous fluids were administered. All anastomoses were the open, two layer type, using nonabsorbable suture material. All abdominal incisions were closed primarily. There were no operative deaths, anastomotic leaks, intra-abdominal abscesses or fistulas. There were six instances of wound infection. Our results with this type of management compare favorably with those of other surgeons using various modes of preoperative oral antibiotic therapy and suggest that oral preoperative antibiotic therapy may not be necessary in elective operations on the colon.

When to ambulate the patient with a vascular graft in the groin

Ankle blood pressure studied pre- and postoperatively in 60 patients after aortofemoral and femoral distal bypass surgery showed no adverse effect after major positional changes (supine, sitting, and standing). Early ambulation was not harmful to graft dynamics in this group of patients.

A humoral factor in the plasma of dogs with hemorrhagic hypotension causing histopathologic changes when infused into normals

The presence of circulating factors in the plasma of shocked dogs which would be capable of causing lung lesions when infused into normotensive dogs was demonstrated by light and electron microscopy. Light microscopy only identified significant differences in atelectasis, vascular congestion, and interstitial edema in the shock and shock-plasma recipient animals. On electron microscopy, interstitial edema and disruption of collagen bundles were consistently found in shocked dogs and in dogs that had received shocked plasma. There was a consistent increase in pulmonary interstitial sodium in both shock and shock-plasma recipient groups. It is concluded that a plasma factor present in the serum of shocked dogs may be transferred to other dogs and cause histopathologic changes seen in the lungs of shocked animals.

Reversal of histopathologic pulmonary changes with indomethacin

There are pulmonary changes documented by light and electron microscopy in a canine model of nonhypotensive shock induced by a lower limb tourniquet. These histopathologic changes are mediated, at least in part, when the dog is treated with indomethacin.

The arteriovenous fistula. Its construction in the management of hemophilia

Arteriovenous fistulae using expanded polytetrafluorethylene (E-PTFE [Gore-Tex]) grafts were constructed in six patients with hemophilia for long-term vascular access where veins had been obliterated. The range of patency was four to 28 months, with a mean of 20 months. All patients had less than 8% level of factor VIII, which may have contributed to fistula patency. This approach was helpful in the management of these patients' conditions.

Effect of hemorrhagic hypotension and hypoventilation on lower esophageal sphincter pressure

Dysfunction of the lower esophageal sphincter has been demonstrated in the cat shock model. Analogies have been drawn to reflux and aspiration in the critically ill patient. In a cat shock model, lower esophageal sphincter pressure is reduced and response to bethanechol is impaired. Upon resuscitation to basal state with heparinized shed blood, the lower esophageal basal pressure returns to normal values, and response to bethanechol is restored. This model may explain reflux and aspiration in the critically ill patient.

The effect of azathioprine on the lung after hemorrhagic shock: a histopathologic study

A study of hemorrhagic shock in anemic dogs suggested a difference in pulmonary histopathology between animals treated with azathioprine and animals in a control group. Hemorrhagic shock for 2 hours without reinfusion produced definite changes in pulmonary anatomy by conventional histology and electron microscopy. The changes consisted of interstitial edema, vascular congestion, and focal atelectasis. Electron microscopic studies showed accumulation of edema fluid with disruption of Type II pneumocytes and the collagen fibrils in the alveolar-capillary interstitium. Azathioprine ameliorated the shock state.

Pregnancy and thrombophlebitis

There is an increased risk of thromboembolic disease during pregnancy. Diagnosis is accomplished through noninvasive measuring, impedance plethysmography and Doppler ultrasound. It is best managed by heparin therapy.

Mechanical characteristics of the cat pylorus

In vitro force-length curves of rings from the gastroduodenal junction were obtained in standard tyrode solution, in tyrode with 140 mM KCl, and in calcium-free tyrode with 5 mM sodium EDTA, to determine basal, total, and passive forces, respectively. Active force was obtained as a difference between total and passive forces. Basal, total, passive, and active forces were higher for pyloric rings than for duodenal and antral rings. Furthermore, in the pylorus the force-length curves were shifted to the left along the length axis due to a narrowing at the gastroduodenal junction. Pressure-diameter relationships calculated from the in vitro force-length data and compared with previously determined in vivo pressure-diameter data, demonstrated good correlation between the in vivo and in vitro data. These data indicate that the higher forces and pressures observed in the pylorus are due to a combination of higher active and passive components. At low levels of stretch, the active forces are higher, while at high levels of stretch the passive forces become prevalent. These data suggest that, because of its passive properties the pylorus may act as a stricture and resist opening to large diameters, thus impeding the passage of large boluses. Near closure, however, any pressure gradient at the gastroduodenal junction would be due to active contraction of the pyloric circular muscles, and thus be susceptible to modulation through neural and/or myogenic factors.

Group rehabilitation for the vascular-disease amputee

Group therapy for lower-extremity, vascular-disease amputees was successful in the return of these patients to their normal milieu. Thirty men (mean age, 63 years) were studied during a one-year period. The group meetings progressed from a phase of directed therapy to one of nondirected therapy. This group of hospitalized amputees was chosen specifically because of its social, economic and medical identity. After a self-identified adequate period of therapy, all patients returned to their former places in society.

Retroperitoneal cross pelvic bypass grafts

An extraperitoneal retropubic cross iliac artery bypass graft is a safe alternative to an intra-abdominal aortoiliac bypass, axillofemoral bypass or subcutaneous femorofemoral bypass in the patient considered to be at high risk. This procedure may prove to be superior to subcutaneously placed grafts because the graft is less prone to trauma and infection. The circulation of the donor limb must be adequate to produce a significant increase in the rate of flow through the recipient limb. There was an early patency of the graft in 58 of 61 patients. There was patency of the graft at three years in 40 of 61 patients.

Amelioration of pancreatitis with azathioprine

An experimental method was developed for the production of acute hemorrhagic pancreatitis of uniform lethality in dogs, using the injection of a bile trypsin mixture into the major pancreatic duct. Fifteen of the 20 dogs treated with azathioprine survived as opposed to none of the ten treated conservatively.

Surgical management of venous stasis disease: an update

The management of leg ulcers of venous origin begins with patient cooperation. Bed rest, leg elevation, and local care should relieve pain and initiate healing. This can be facilitated or managed on an outpatient basis by using an Unna's boot. Superficial varicosities should be ligated and stripped, and perforators identified by venography should be ligated and divided subfascially. Ulcers can then be excised and grafted. Long-term care includes chronic use of compression hose.