The lateral island trapezius myocutaneous flap for circumferential reconstruction of hypopharynx and cervical esophagus

The lateral island trapezius was utilized for reconstruction of hypopharyngeal and cervical esophagus defects in high-risk patients, avoiding entry into the celomic cavities as an approach to decrease morbidity and mortality. Seven male patients were treated at the State University of New York between 1988 and 1991 and underwent reconstruction with the lateral island trapezius flap. There was no mortality, 2 patients developed pharyngocutaneous fistulas; 1 patient operated after radiation treatment failure remained with positive margins at resection but his fistula never healed, and another patient underwent a minor revision with successful closure of the fistula. All patients regained swallowing and none required dilatations. The preferred methods of reconstruction for the reasonable risk patient are gastric pull-up and free jejunal transfer; both of which require entry into cavities. The lateral island is a reliable alternate method of reconstruction for high-risk patients in whom intracavitary surgery may lead to unacceptably high morbidity and mortality. When the vascular anatomy is not favorable, rerouting of the vessels may be required utilizing microvascular reconstruction. The donor site defect is closed primarily or skin grafted, and subsequent functional limitations are minimal and well tolerated.

Pressure control inverse ratio ventilation in the treatment of adult respiratory distress syndrome in patients with blunt chest trauma

The objective of this study was to evaluate the efficacy of pressure control inverse ratio ventilation (PCIRV) in improving oxygenation in trauma patients with adult respiratory distress syndrome (ARDS) and to assess the potential risks associated with this form of treatment. This was a cohort study assessing the trends in hemodynamic and ventilatory parameters after the initiation of PCIRV, conducted at a community Level I trauma center intensive care unit. The study comprised 15 trauma patients developing severe, progressive ARDS [two or more of the following criteria: positive end-expiratory pressure (PEEP) >10 cm H2O; arterial partial pressure of oxygen divided by fraction of inspired oxygen (PaO2:FiO2) ratio <150; and peak inspiratory pressure (PIP) >45 cm H2O]: ten due to blunt chest injuries, three due to sepsis, and two due to fat emboli syndrome. PCIRV was initiated. Main outcome measures were PIP, PEEP (total, auto), oxygen saturation, cardiac index, oxygen delivery, PaO2:FiO2 ratio, compliance, evidence of complications of PCIRV, and mortality. Within 24 hours of conversion to PCIRV, the patients stabilized and the mean PaO2:FiO2 ratio rose from 96.3+/-57.8 to 146.8+/-91.1 (P<0.05) and PIP fell from 47.9+/-13.8 to 38.8+/-8.4 cm H2O; auto-PEEP increased from 0.5+/-1.9 to 7.5+/-5.6 cm H2O (P<0.05); oxygen delivery index remained stable (563+/-152 to 497+/-175 mL/min/m2); three patients developed evidence of barotrauma, one patient developed critical illness polyneuropathy, and two patients died (13%). PCIRV is an effective salvage mode of ventilation in patients with severe ARDS, but it is not without complications. Auto-PEEP levels and cardiac index should be monitored to ensure tissue oxygen delivery is maintained.

Traditional criteria for observation of splenic trauma should be challenged

Age less than 55 years, normal Glasgow Coma Score (GCS), and absence of hypotension are traditional criteria for the selection of adult patients with blunt splenic trauma for observation. The objective of this study is to challenge these criteria. Two hundred twelve patients who presented with blunt splenic injury between 1992 and 1997 were identified from the Trauma Registry at our Level I trauma center. The patients were divided into three groups: 100 patients (47%) were observed, 108 (51%) underwent immediate splenorrhaphy or splenectomy, and 4 (2%) failed observation. The three groups were compared by participants' ages, GCSs, and histories of hypotension. No statistical differences were noted between the successfully observed patients and those requiring immediate surgery with respect to these criteria. Of the 4 patients who failed observation, all were younger than 55 years, all had a GCS >12, and all were normotensive. Our findings suggest that traditional criteria used to select patients for splenic trauma observation are not absolute indicators and should be liberalized: patients can be successfully observed despite having criteria that, in the past, would have led to immediate operative intervention.

Reduced use of resources by early tracheostomy in ventilator-dependent patients with blunt trauma

BACKGROUND

Early tracheostomy has been advocated for ventilator-dependent patients with blunt trauma, but its advantages have not been examined critically.

METHODS

We retrospectively reviewed our experience with all patients with blunt trauma undergoing tracheostomy during the 6-year period from 1990 to 1995. Patients undergoing tracheostomy within the first 6 days of hospitalization were designated as early recipients (ET) and those undergoing the procedure at 7 or more days were defined as late recipients (LT).

RESULTS

The entire study group consisted of 157 patients. The ET group contained 62 patients and the LT group contained 95 patients. No statistical differences were noted between the 2 groups with respect to sex distribution, injury severity scores, probability of survival scores, or mortality rates. The mean stay in the intensive care unit for the ET group was 15 days compared with 29 days for the LT group (P < or = .001). The mean total hospital stay for the ET group was 33 days compared with 68 days for the LT group (P < or = .001). The mean estimated per-patient hospital charges for only room and ventilator care were $36,609 for the ET group compared with $73,714 for the LT group.

CONCLUSIONS

ET in this patient group resulted in significantly lowered use of resources with no adverse effect on outcome.

Improved selection criteria for ordering stat venous ultrasounds from the emergency department

BACKGROUND

The accuracy and convenience of venous ultrasound (VU) to exclude deep vein thrombosis (DVT) has led to indiscriminate use and low positive yield rates.

METHODS

A total of 256 patients were referred from our emergency department (ED) for stat VU during a 2-year period (1995 to 1996). The VUs were interpreted as normal in 198 (77%). Positive findings were discovered in 58 (23%), with DVT accounting for 43 (17%). Retrospective multivariant analysis was used to identify predictive indicators.

RESULTS

Unilateral leg swelling/edema identified 36 of 40 (90%) patients with DVT and 8 of 10 (80%) with other thrombotic disorders (saphenous and/or chronic venous thrombosis). A history of leg pain with prior DVT or recent trauma < or =3 days' duration increased DVT duration to 98% (39 of 40). Using these criteria, a 47% charge reduction would have been recognized.

CONCLUSIONS

Improving ED screening criteria can safely increase yield rate and reduce charges with minimal loss of VU sensitivity.

Incidental Meckel's diverticulectomy in adults

BACKGROUND

Incidental Meckel's diverticulectomy has been advocated by some surgeons because of the lower associated morbidity and mortality in this setting than when resection is indicated. Others have argued that the low risk of complication occurrence does not justify prophylactic removal. The issue remains controversial.

METHODS

Medical records of all adults undergoing Meckel's diverticulectomy at four acute care hospitals during the 5-year period 1989 through 1993 were retrospectively reviewed. Decision analysis was used to determine relative risks for incidental resection compared to indicated resection for a complication.

RESULTS

Ninety patients underwent incidental diverticulectomy. Morbidity was 2% and mortality 0%. Four patients underwent resection for a complication of their diverticulum. Morbidity and mortality were each 0%. Combining these results with previously reported results and using decision analysis, the conditional probabilities of producing surgical morbidity or mortality in the adult population at risk by only resecting symptomatic diverticula are 0.2% and 0.04%, respectively. The comparable risks for resecting all incidentally discovered diverticula are 4.6% and 0.2%.

CONCLUSIONS

Incidental diverticulectomy in adults should be abandoned.

Craniofacial trauma in injured motorcyclists: the impact of helmet usage

Helmets are effective in decreasing maxillofacial trauma in motorcycle crashes. The impact, however, of motorcycle crashes on the location and patterns of craniofacial injuries among helmeted versus unhelmeted patients has not been examined. In the present study, 331 injured motorcyclists were evaluated to compare the incidence of craniofacial and spinal injury in 77 (23%) helmeted and 254 (77%) nonhelmeted patients. Nonhelmeted motorcyclists were three times more likely to suffer facial fractures (5.2% vs. 16.1%) than those wearing helmets (p < 0.01). Skull fracture occurred in only one helmeted patient (1.2%), compared with 36 (12.3%) of nonhelmeted patients (p < or = 0.01). The incidence of spinal injury was not significantly different between the two groups. Blood alcohol levels demonstrated that 12% of the helmeted group were legally intoxicated (blood alcohol level > 100 mg/dL), in contrast to 37.9% of the nonhelmeted motorcyclists (p < or = 0.01). Failure to wear a helmet resulted in a significantly higher incidence of craniofacial injury among patients involved in motorcycle crashes, but did not affect spinal injury or mortality. Alcohol usage seemed to correlate with failure to use helmets. Helmet use should be legally mandated on a national level for all motorcyclists.

Determination of brain death with use of color duplex scanning in the intensive care unit setting

OBJECTIVE

To determine if color flow duplex scanning (CFDS) can be used for rapid confirmation of presumed brain death.

DESIGN

Pilot cohort study comparison of CFDS with radionuclide cerebral scanning (RCS) as the criterion standard.

SETTING

Community-based level I trauma center intensive care unit.

PATIENTS

Twenty-four patients who satisfied criteria for presumed brain death.

MAIN OUTCOME MEASURE

Confirmation of presumed brain death.

RESULTS

CFDS correctly identified 16 of 24 patients as brain dead, confirmed by RCS. Eight patients with brain flow on RCS were also correctly identified by CFDS. Only two of 24 patients survived their severe injuries.

CONCLUSIONS

CFDS provides a uniform, cost-effective diagnostic tool for rapid confirmation of clinical brain death with 100% accuracy. Its use should complement RCS, given its rapid interpretation, portability, and economical assessment of presumed brain death.

Cost-effectiveness of laparoscopic cholecystectomy

This study retrospectively evaluated the cost-effectiveness of laparoscopic cholecystectomy compared to open cholecystectomy in a single university-affiliated community hospital. The medical records of all patients that underwent laparoscopic cholecystectomy during 1990 and open cholecystectomy during 1989 in one hospital were reviewed. Hospital stay, hospital charges, surgeons' and anesthesiologists' fees were determined. Fifty patients from each group were contacted to determine recovery time to full activity after surgery. Those having common duct exploration and those converted to open cholecystectomy after an attempted laparoscopic cholecystectomy (n = 8) were excluded. A summary of results is included below (Table 1). In our early experience with laparoscopic cholecystectomy we found that the total charges for laparoscopic cholecystectomy were more than for open cholecystectomy when one recognizes the 1-year difference in patient accrual between the two groups. Time to full recovery was markedly reduced in patients undergoing laparoscopic cholecystectomy compared to those having an open procedure. Despite the overall increased total charge with laparoscopic cholecystectomy, the shorter recovery period allowing the patients an earlier return to full preoperative activities contributes to its cost-effectiveness when compared to open cholecystectomy. Further experience with laparoscopic cholecystectomy and refinements in management of these patients should allow for further reductions in charges for this procedure.

Traumatic incarceration of the small bowel: case report

While bowel injuries associated with blunt abdominal trauma are a well recognized entity, entrapment of bowel between vertebral bodies has seldom been described. The unusual case of traumatic jejunal incarceration between two lumbar vertebrae is presented.

The deltopectoral triangle as a landmark for percutaneous infraclavicular cannulation of the subclavian vein

An anatomic landmark is identified and described that simplifies the technique of central venous cannulation via the subclavian vein. The commonly used techniques are an approach to the subclavian at the junction of the medial and middle thirds of the clavicle or at the midclavicular line. A described anatomic landmark, the deltopectoral triangle, is easily identified in virtually all patients and requires no measuring or extensive knowledge of anatomy for localization. Penetration of the skin at this landmark facilitates the procedure and produces less patient discomfort. Using this technique, the authors have successfully cannulated the subclavian vein in 92.7% (51/55) of attempts with a 5.5% (3/55) complication rate. The only complications were arterial punctures, which were treated with pressure and were of no consequence to the patient.

Risk of pulmonary emboli in patients with pelvic fractures

Multiply-injured patients with pelvic fractures are recognized to have an increased risk of deep venous thrombosis. The incidence of pulmonary emboli in patients with this injury has been reported to range from 0.5 to 8.3 per cent in several recent reviews. One hundred ninety-eight patients with pelvic fractures treated at a regional trauma center over a 3-year period were reviewed to evaluate the factors associated with an increased risk of clinically evident pulmonary embolism. The mean age SD was 44 24 years; 51 per cent were male, and mean Injury Severity Score (ISS) was 19 15. Eighteen patients (9%) died. Mortality was significantly correlated with ISS (P < 0.05), male sex, and type and severity of fracture but not with age, mechanism of injury, or operative fixation. Four patients (2.0%) had pulmonary emboli. The occurrence of clinically apparent pulmonary emboli correlated only with ISS (ISS < 15 = 0% vs ISS > 15 = 4%, P < 0.05). During the same time period, there were eight (0.2%) pulmonary emboli in 3337 trauma patients without pelvic fracture. This difference is highly significant (P < 0.0001). Pelvic fracture is indicative of severe injury and denotes a population at higher risk for pulmonary emboli than other trauma patients. Intensive screening and prophylactic measures to prevent deep venous thrombosis and subsequent pulmonary emboli should be intensively directed at this population.

Adjunctive vasodilator therapy in the treatment of murine ischemia

Potent vasoconstrictors such as angiotensin II and vasopressin have been implicated as mediators of persistent vasoconstriction after reversible superior mesenteric artery (SMA) occlusion. Neither captopril (CAP), an angiotensin-converting enzyme (ACE) inhibitor, nor papaverine (PAP), a vasodilator, has proven effective in reversing this vasoconstriction when employed singly. The present study examined the combined effect of these agents in reducing mortality in a murine model of acute mesenteric ischemia. The SMAs of 106 adult male Sprague-Dawley rats were totally occluded for 85 minutes. Test agents were given intravenously at reperfusion over a 90-minute period. Survival rates were assessed at 48 hours. CAP was given as a single bolus (0.3 mg/kg) and PAP (0.5 mg/kg/h) as an infusion. Aortic and SMA blood flows were measured pretreatment and posttreatment in a separate group of 19 animals treated with CAP and PAP as single agents. chi 2 analysis and analysis of variance were used to test differences with p < or = 0.05 accepted as significant. PAP alone as an adjunct resulted in a significant increase in 48-hour survival (57% versus 19%, p < or = 0.005). PAP in combination with CAP produced the best outcome in this model (87% versus 19%, p < or = 0.005). Aortic blood flow decreased, whereas SMA blood flow increased after treatment both with CAP and with PAP, but not significantly. The combination of an intravenously administered vasodilator with either glucagon or an ACE inhibitor was the most effective adjunctive therapy in this mesenteric ischemia model. There was no evidence that an inotropic effect, rather than SMA vasodilation, was the responsible mechanism of action.

Nonfunctioning parathyroid carcinoma

Parathyroid carcinoma is a rare clinical entity accounting for only 4 per cent of all cases of parathyroid neoplasia. Nonfunctioning parathyroid carcinoma is even rarer. Previously, virtually all patients with these lesions were treated for a nonspecific neck mass. However, in the present case, a preoperative diagnosis of nonfunctioning parathyroid carcinoma was made based on the technetium pertechnetate/thallium 201 subtraction scan. The authors report on the 14th case of nonfunctioning parathyroid carcinoma, a review of the literature, and guidelines for the preoperative and operative evaluation of neck masses suspected to be parathyroid carcinoma.

Combined use of topical and systemic antibiotics

An animal wound model was used to compare the effectiveness of topical and systemic antibiotics and to examine the validity of using a combined regimen of both routes of antibiotic delivery. Gross infection rates and wound bacterial concentrations were determined after contamination with Staphylococcus aureus or Escherichia coli. Both moderate (10(8) colony-forming units [CFU]) and heavy (10(12) CFU) contamination were studied for each organism. Following moderate contamination, topical and systemic antibiotics were equally effective in reducing both wound bacterial content and infection rate, but there was no benefit from the combined use of both modes of antibiotic delivery. An additive effect of the combined regimen was noted only when the level of wound contamination was heavy.

Mesenteric venous thrombosis: ten year record review and evaluation of difficulties with the ICD coding system

A 10-year retrospective review of mesenteric venous thrombosis was accomplished in one metropolitan city. This paper discusses 14 patients with a confirmed diagnosis of mesenteric venous thrombosis. This review also yielded an important realization of an inadequacy of the International Classification of Diseases, 9th edition in coding for mesenteric venous thrombosis. This paper discusses this difficulty in the International Classification of Diseases.

Are pancreatoenteric anastomoses improved by duct-to-mucosa sutures?

The patency of anastomoses joining the pancreas to either a Roux-Y loop of jejunum or the stomach was evaluated in 26 dogs. At a preliminary operation, the head and uncinate process of the pancreas were resected while carefully preserving the duodenal blood supply. The remaining body and tail of the pancreas were totally obstructed. After obstruction for a mean of 22 (range: 6 to 42) days, one of three anastomoses was performed: (1) inversion pancreatogastrostomy with two layers of sutures; (2) a similar inversion pancreatojejunostomy to the side of a Roux-Y jejunal loop; or (3) pancreatojejunostomy in which the major duct was joined to the jejunal mucosa with interrupted sutures. Six animals were kept for controls. Anastomotic patency was assessed after 8 to 12 weeks by pancreatography, with minimal pressures to achieve anastomotic flow recorded. Weight trends were consistent with anastomotic status. The eight dogs with duct-to-mucosa sutures clearly achieved superior anastomotic patency.

Operative therapy for sigmoid volvulus. Identification of risk factors affecting outcome

The medical records of 54 patients treated for sigmoid volvulus from 1983 to 1987 were reviewed. Patient demographics were very similar to previously published results. Four patients (7.4 percent) underwent emergency resection for gangrene with a mortality of 75 percent. Of the 50 patients who presented without ischemia, 23 (46 percent) were managed by nonoperative detorsion while 3 (6 percent) detorsed spontaneously. Fourteen of these 26 patients received no further treatment. Nonoperative mortality was 0 percent. Celiotomy was performed on 36 patients. The type of operative procedure performed had no significant bearing on outcome. Fifteen patients underwent resection and anastomosis; two of these patients died (13 percent). Fifteen patients underwent resection and colostomy with two deaths (13 percent), and six had open detorsion alone with one death (17 percent). The two factors associated with adverse outcome after surgical intervention were patient age and history of previous volvulus. All five deaths occurred in patients older than 70 years presenting with a first episode of volvulus (N = 15, mortality = 33 percent). No deaths occurred among patients younger than 70 years regardless of volvulus history or among those older than 70 years who were being treated for a recurrence (P less than or equal to 0.01). Patients older than 70 years with a first episode of volvulus represent a high risk if subjected to surgical intervention. Nonoperative detorsion alone should be considered for this subgroup of patients.

A study of the on-duty hours of surgical residents

A time study was done to ascertain the number of hours spent in the hospital and the types of duties performed by residents enrolled in a multiple-institution, university-sponsored surgical training program. On the average, residents in the Wright State University program spent 90.1 +/- 27.1 hours in the hospital per week. Direct patient care activities required 62.7 +/- 18.8 hours (69.6%) of the average workweek. Purely educational endeavors accounted for 10.0 +/- 6.1 hours (11.1%) of the workweek. Ancillary tasks consumed an average of 8.5 +/- 8.5 hours (9.4%) of the surgical residents' time on duty per week. House officers did obtain a mean of 9.1 +/- 11.0 hours of sleep in those working hours (10.1% of the total time spent in the hospital). Although much variation existed among hospitals in the program, on-duty hours were greater in the private hospitals compared to the federal hospitals; the principal difference was the amount of time spent doing ancillary tasks (10.0 +/- 9.4 hours vs 5.6 +/- 5.6 hours; p less than 0.01). Hours worked by residents on private surgical services were longer than those of residents assigned to staff services (96.4 +/- 22.1 hours vs 86.0 +/- 29.3 hours; p less than 0.04). Again, the major difference was the greater amount of ancillary tasks performed by residents on private services (12.0 +/- 9.5 hours vs 6.2 +/- 7.0 hours; p less than 0.001). This finding could not be attributed to differences in patient census or turnover rates. Longer hours were noted on the general/thoracic surgery services compared to other surgical subspecialties (94.1 +/- 27.3 hours vs 81.5 +/- 24.8 hours; p less than 0.02). More time was spent in direct patient care on general/thoracic surgery (66.3 +/- 19.3 hours vs 54.9 +/- 15.1 hours; p less than 0.002). Despite the shorter workweek, residents on subspecialty rotations spent more time doing ancillary tasks (11.3 +/- 9.7 hours vs 7.3 +/- 7.6 hours; p less than 0.02). More than 60% of the residents' working hours in this program exceeded the arbitrary 80-hour limit, emphasizing the challenge of complying with the imposition of maximum work hours. We recommend that each program closely monitor the activities and hours of its residents to best respond to the pressures for regulation.

Assessing the role of routine choledochoscopy during exploration of the bile duct

Two hundred and five consecutive explorations of the common bile duct were evaluated to assess the value of routine choledoschoscopic examination in preventing retained stones. Conventional exploration was performed in 139 instances (group 1), while routine choledochoscopy was added in 66 procedures (group 2). Preoperative temperature, leukocyte count, total bilirubin, amylase and alkaline phosphatase levels were not significantly different between the groups. Nine retained stones were demonstrated by postoperative cholangiography among the patients in group 1 as compared with three retained stones noted in those in group 2. This difference was not significant. Postoperative mortality and complication rates were unaffected by the performance of an endoscopic study of the biliary tract during ductal exploration. Choledochoscopy added an average of 36 minutes to the duration of the operative procedure (p less than 0.001). Choledochoscopy may prove helpful in selected instances, but the current data do not support its routine use during exploration of the common bile duct.

Reassessment of primary resection of the perforated segment for severe colonic diverticulitis

Primary resection with colostomy has been widely adopted during the past decade for the treatment of patients with severe complications of diverticulitis. Because of this, a retrospective review was performed of all patients undergoing surgery for colonic diverticular disease during the two time periods 1974 to 1978 (n = 196) and 1982 to 1986 (n = 230). Forty-three patients had abscess or peritonitis from 1974 to 1978, whereas 52 had these complications from 1982 to 1986. Colostomy and drainage alone were used for 31 of 43 patients (72%) from 1974 to 1978, while primary resection with colostomy was used for 39 of 52 patients (75%) from 1982 to 1986 (p less than or equal to 0.5). Despite this shift in treatment method, mortality increased from 14% in 1974 to 1978 to 19% in 1982 to 1986 (p = NS). Patients with peritonitis had identical mortalities (22%) during both intervals. Patients with abscess experienced an increase in mortality from 8% in 1974 to 1978 to 15% in 1982 to 1986 (p = NS). The widespread use of primary resection for patients with severe complications of diverticulitis appears not to have altered mortality for those with diffuse peritonitis and may have worsened the outcome for those with abscess.

The role of pH in altering serum ionized calcium concentration

Although parathormone primarily determines normal ionized serum calcium concentration [Ca++] over the long term, it has little impact in the acute situation. Nonhormonal changes in [Ca++] have been related to acute changes in serum pH, but these have been believed small. With use of an experimental model of acute pancreatitis, we measured changes in [Ca++] and related them to changes in other serum constituents known to affect it. All 18 animals studied experienced a decrease in total serum calcium concentration [CaT]. Changes in [CaT] correlated only with changes in protein-bound calcium concentration [CaP] (r = 0.98, p less than or equal to 0.0005). They did not correlate independently with changes in albumin, globulin, or total protein concentration. [CaP] varied as a function of albumin, globulin, and phosphate concentration and pH according to the equation: [CaP] = 17.9 +/- 0.89 [albumin] = 0.68 [globulin] - 2.5 pH + 0.12 [phosphate]. Calculated values for [CaP], when this equation was used, correlated strongly with observed values for [CaP] (r = 0.81, p less than or equal to 0.0005). Measured [Ca++] increased in the animals early during pancreatitis and then returned to baseline levels. A few animals experienced ionized hypocalcemia. [Ca++] correlated only with changes in pH (r = 0.87, p less than or equal to 0.02). The calculated response slope was delta [Ca++]/delta pH = -2.9. It is concluded that pH has a greater effect on [Ca++] than previously recognized. The major determinant of [CaT] during periods of rapid physiologic change appears to be [CaP] while that for [Ca++] is pH.

Comparison between externally stented and unstented PTFE vascular grafts

It has been suggested that external stenting of synthetic vascular prosthetic material may improve patency rates in the low flow situation or across joints. This study compared externally stented polytetrafluoroethylene (PTFE) vascular grafts placed across the hip joint in dogs with nonstented PTFE grafts in regard to patency. Twenty animals underwent bilateral common iliac to common femoral artery bypass with proximal ligation of the femoral artery. In each animal one groin was randomly assigned to receive stented PTFE and the other nonstented PTFE. One animal was sacrificed at 2 weeks for graft infection. Nineteen animals received 38 grafts that remained in place 90-120 days. Patency was confirmed with angiography prior to sacrifice. Overall patency was 65 per cent with no significant difference between the two types of graft. Eighteen of 19 dogs (95%) had both the stented and nonstented PTFE grafts either open or closed. It is concluded that intrinsic factors, rather than external graft support, are a more important influence on graft patency in this model.

Efficacy of sucralfate in preventing peptic ulceration induced by nonsteroidal anti-inflammatory drugs

The nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used analgesics associated with a significant incidence of gastritis and/or peptic ulceration. This study was designed to evaluate the efficacy of sucralfate (SC) in reducing NSAID-induced ulceration in a rat model. Nine groups of 20 rats each were segregated by drug(s) tested. Two NSAIDs, aspirin (ASA) and indomethacin (IND), were tested. Control groups consisted of saline only, ASA only, and IND only. SC was tested against ASA and IND separately, being administered 5 minutes preceding, mixed with, or 5 minutes following each NSAID. Administration of SC before ASA resulted in a reduction of mean ulcers per rat from 10.4 +/- 4.3 to 1.1 +/- 1.3 (P less than or equal to .0001). Administration of SC prior to IND resulted in a reduction of mean ulcer rate from 6.6 +/- 5.4 to 3.0 +/- 3.3 (P less than or equal to .02). When SC was given with IND or following it, no reduction in ulcer rate was observed. When SC was given with ASA or following it, the ulcer rate was reduced to 5.3 +/- 3.0 (P less than or equal to .002). It is concluded that SC is effective in reducing NSAID-induced ulcer production especially when administered before NSAID ingestion.

Candida and perforated peptic ulcers

Patients with perforated peptic ulcers who have Candida isolated from peritoneal culture have been noted to have a poor prognosis. Therefore treatment of such patients with systemic antifungal agents has been considered. Because of the toxicity and expense of such therapy, a review of the association was performed. During 1980 to 1985, 48 patients were operated on for benign perforated ulcer. The mean age of the patient group was 66 years. Intraoperative cultures were obtained in 38 patients. Microorganisms were isolated in 28 (74%) patients. Candida was isolated in 16 (57%) of the positive cultures. The overall mortality rate was 16.7%. The mortality rate for patients 65 years of age or older was 25% compared with 0% for those younger than 65 years old. The mortality rate for patients with Candida in their peritoneal fluid was 18.8%. No patient was treated with systemic antifungal agents. No patient developed candidiasis. Of the 16 patients in whom Candida was isolated, it was the only organism in 10 patients and was found in mixed culture with bacteria in six. The mortality rate for patients with Candida alone was 0%. The mortality rate for patients with mixed cultures was 50%. The presence of mixed cultures correlated strongly with both advanced patient age and shock. These factors have previously been correlated with death. It is concluded that the association between peritoneal Candida and excessive death from perforation is linked by an intervening association to advanced age and shock. In this setting, Candida does not appear to be normally pathogenic and does not require systemic antifungal therapy.

Peptic ulcer disease and the nonsteroidal anti-inflammatory drugs

The medical records of 265 patients with peptic ulcer disease were reviewed for a history of nonsteroidal anti-inflammatory drug (NSAID) use preceding hospital admission. Ninety-five patients (36%) gave a history of regular use of such agents. The admission characteristics of the peptic ulcer patient group not using NSAIDs (age, sex, ulcer location, admission indication, method of diagnosis) were virtually identical to those of the group taking NSAIDs. Although 24.5 per cent of patients not taking NSAIDs were admitted because of hemorrhage from their ulcer compared with 28.4 per cent of NSAID users, only 7.5 per cent of nonusers required surgery for hemorrhage control compared to 29.6 per cent of users. Eighty per cent of patients regularly using more than one NSAID required surgery for an ulcer complication. Hemorrhage mortality was 5 per cent among nonusers compared with 14.8 per cent among users. It is concluded that NSAID use by patients with peptic ulcers adversely affects therapeutic response in general and significantly impairs normal hemostatic mechanisms in patients bleeding from an ulcer.

Surgical aspects of Clostridium septicum septicemia

Clostridium septicum is a virulent cause of gas gangrene and sepsis. Although thought to be rare, a survey of our affiliated hospitals for a recent five-year period disclosed eight cases. Seven of the eight had an occult malignant neoplasm. The eighth patient was thought to be preleukemic. All seven malignant neoplasms involved the gastrointestinal tract. Four patients were admitted with gangrene of an extremity, three with abdominal pain, and one with both. In four patients, C septicum septicemia appeared in an extremity before the underlying gastrointestinal malignant neoplasm was recognized. Four patients had surgical therapy and two survived; four received medical therapy and one survived. Patients who have C septicum septicemia should be assumed to harbor an underlying malignant neoplasm until proved otherwise.

Malignant fibrous histiocytoma of the ileum

Malignant fibrous histiocytoma occurs most commonly in the extremities and trunk, but rarely in visceral organs. This report documents a case of malignant fibrous histiocytoma arising in the terminal ileum. Following surgical resection, there is no evidence of recurrence or metastasis in this patient after one-year follow-up studies.

Preoperative predictors of postoperative pain

This study attempted to predict postoperative pain from preoperative level of anxiety and the amount of information patients possessed regarding their surgery. Pain was assessed via the McGill Pain Questionnaire (MPQ) and a measure of pain complaints--number of analgesics taken. High levels of state anxiety and a high degree of information predicted the Present Pain Intensity measured of the MPQ, but did not predict the Pain Rating Index portion of the MPQ. The number of analgesics taken was predicted from the amount of information but not the level of presurgical anxiety. Biographical variables were unrelated to postoperative pain. The results were discussed in terms of State-Trait Anxiety theory, Janis' curvilinear prediction model and a contextual perspective of information imparting.

The effects of dehydration on the dynamics of transcapillary refill

Since the water reserve of the interstitium plays a major role in circulatory homeostasis, its reduction by dehydration may produce severe changes in the organism's response to hemorrhage but this has not been measured experimentally. Twelve immature pigs (22 +/= 2 Kg) were divided into two groups of six each. Control animals had free access to food and water prior to bleeding. Dehydrated animals had water withheld for 48 hours preceding the bleeding. All animals were bled 30 per cent of their calculated blood volumes while awake. No resuscitation was performed. No mortality was observed in the control group of animals, while four of the six dehydrated animals died (66%). All deaths occurred between one and four hours posthemorrhage. Plasma refill reached 33 per cent by 0.5 hours in the control group compared to only 17 per cent by 0.5 hours in the dehydrated group (p less than or equal to .05). Refill in the control group reached 50 per cent by three hours, whereas dehydrated animals surviving to three hours demonstrated no further refill (p less than or equal to .05). BUN, calcium, sodium, and osmolality were consistently higher in dehydrated than control animals (p less than or equal to .05). It is concluded that a reduction in the interstitial water reserve significantly impairs ability to recover from hemorrhage.

Mechanisms of hypocalcemia in acute hemorrhagic pancreatitis

Thyrocalcitonin release mediated by glucagon secreted from the acutely inflamed pancreas has been postulated as a possible mechanism for hypocalcemia in acute pancreatitis. To test this hypothesis, hemorrhagic pancreatitis was induced in a group of thyroidectomized pigs. No source of thyrocalcitonin other than the thyroid has been described in the pig. Their subsequent serum calcium concentrations were compared with those in a group of thyroid intact pigs also given hemorrhagic pancreatitis. The results indicate that the hypocalcemia observed during the first 24 hours following induction of pancreatitis is not related to the presence of an intact thyroid. Differences observed in the degree of hypocalcemia between the two groups 30 to 48 hours after pancreatitis developed may be of significance but could be explained by dilutional differences alone. Thyrocalcitonin apparently has little if any role in the hypocalcemia observed during the course of acute pancreatitis.