Comparison of jejunal and ileal surveillance biopsies in a porcine model of intestinal transplantation.

BACKGROUND: The optimal biopsy site of bowel allografts for rejection surveillance remains controversial. We compared the results of jejunal (JBx) and ileal (IBx) biopsies after bowel transplantation in a porcine model. METHODS: Eighteen Yorkshire-Landrace pigs served as donors. Eighteen recipient pigs underwent total enterectomy followed by orthotopic small bowel transplantation with or without the colon. A jejunostomy and a Bishop-Koop ileostomy were constructed for biopsies. Immunosuppression consisted of FK506 (target level 10-15 ng/ml by enzyme immunoparticle assay) and prednisone administered via the jejunostomy. Simultaneous JBx and IBx were performed twice weekly. Acute rejection was graded as mild, moderate, or severe based on previously published criteria. RESULTS: Mean overall survival after the transplant was 17.4 days. A total of 162 specimens were collected and evaluated for rejection (JBx, 81; IBx, 81). Acute rejection was detected in 41 JBx cases (50.7%) and 40 IBx cases (49.4%). The presence or absence of rejection was concordant between JBx and IBx in 70 of 81 case pairs (86.4%). Of the 11 discordant case pairs, 6 were JBx positive/IBx negative, whereas 5 were JBx negative/IBx positive. A total of 35 case pairs were synchronously positive, 24 (68.8%) of which demonstrated the same degree of rejection. CONCLUSIONS: The correlation between JBx and IBx of bowel allografts in diagnosing the presence of acute rejection is quite good. However, performing IBx alone would have missed about 7.5% of the rejection episodes. Because the early treatment of rejection in bowel transplantation is of paramount importance, in selected cases, biopsies from both the ileum and jejunum should be considered if technically feasible.

Pulmonary capillary wedge pressure estimates of left ventricular preload are inaccurate in endotoxin shock: contribution of Starling resistor forces to septic pulmonary hypertension.

We tested the hypothesis that Starling resistor forces play a significant role in the increase in pulmonary vascular resistance during endotoxin shock. Anesthetized pigs (n = 9) were given Escherichia coli endotoxin (ETX; .5 mg/kg intravenously over 30 min). Mean pulmonary arterial pressure (MPAP) and pulmonary capillary wedge pressure (PCWP) were recorded through a Swan-Ganz catheter. Pulmonary capillary pressure (Pc) was obtained from the analysis of the transient pulmonary artery pressure decay curve upon balloon inflation. Both proximal (Ra) and distal (Rv) pulmonary vascular resistance were calculated from cardiac output (CO), MPAP, Pc, and PCWP. Left atrial pressure (LAP) was measured directly via a left atrial catheter. Left ventricular end-diastolic wall thickness (LV-EDWT) was monitored by sonomicrometry, and used as an index of left ventricular preload. The results at baseline (t = 0) and t = 60 (30 min after the cessation of endotoxin infusion) were compared with saline control animals (n = 6). Data were analyzed with a two-way ANOVA followed by contrast of residuals (p < or = .05). After endotoxin, arterial blood pressure and CO fell significantly, an effect not seen in control pigs. In the control group neither LAP nor PCWP changed significantly over time, and remained equivalent to each other. In the septic shock group there was no difference between LAP and PCWP at t = 0. However, by t = 60 LAP dropped and PCWP rose significantly. This fall in LAP and increase in PCWP were significantly different from the time-matched control values, and from each other.(ABSTRACT TRUNCATED AT 250 WORDS)

Adductor canal compression syndrome.

Adductor canal syndrome is an unusual cause of acute arterial occlusion in younger men. It is the result of arterial compression by an abnormal musculotendinous band arising from the adductor magnus muscle and lying adjacent and superior to the adductor tendon. The pathogenetic mechanism of this syndrome resembles that of popliteal fossa entrapment and can become manifest after exercise. Since this syndrome occurs in younger men in whom acute arterial occlusion can lead to limb loss, recognition of the presence of apparent ischemic symptoms after exercise in an otherwise healthy young man is important. The treatment consists of the division of the abnormal band and restoration of arterial continuity by appropriate means. A search for bilateral lesions can help avoid future problems even when the symptoms are unilateral.

Conjugated estrogens for the management of gastrointestinal bleeding secondary to uremia of acute renal failure.

Bleeding commonly occurs secondary to the uremia of acute and chronic renal failure. Hemodialysis is indicated for the management of uremic bleeding, and administration of red blood cells and cryoprecipitate is also helpful. Desmopressin successfully reduces the bleeding tendency in patients with chronic renal failure for short-term operations or procedures, but the frequency of tachyphylaxis is high and limits the drug's usefulness for major bleeds. Conjugated estrogens shorten bleeding times in uremia and may provide a more sustained hemostatic effect over desmopressin. A patient with acute renal failure and uncontrolled gastrointestinal bleeding was successfully treated with conjugated estrogens after failing desmopressin and octreotide therapy.

Simultaneous reconstruction of extensive soft-tissue defects of both lower limbs with free hemiflaps harvested from the omentum.

Simultaneous resurfacing of extensive soft-tissue defects involving both lower extremities can be performed successfully with free hemiflaps harvested from the omentum. This avoids the need for staged operations or for separate donor sites with the concomitant morbidities, the possible need for intraoperative repositioning, and the significantly greater operative time. During the past 3 years, six omental free hemiflaps were performed in three patients for bilateral lower limb reconstruction. All patients had extensive ulcerations, averaging 207.5 cm2 in surface area. Ulcerations were secondary to either homozygous sickle cell anemia (two patients) or chronic venous insufficiency (one patient). Operative time averaged 11 hours for the bilateral procedures. Delayed skin grafting was performed in two patients. All six omental free hemiflaps were successful. Partial skin-graft loss due to infection occurred in both sickle cell anemia patients. Significant improvement in symptoms was noted in all patients. There were no donor-site complications. Free hemiflaps harvested from the omentum can provide sufficient well-vascularized tissue with large-caliber vessels for coverage of separate extensive soft-tissue defects in one operation with minimal donor-site morbidity, making this an ideal flap option when multiple sites are involved.

Spontaneous rupture of the spleen in infectious mononucleosis: a failed attempt at nonoperative therapy.

Rupture of the spleen in infectious mononucleosis is a rare but potentially fatal complication. Once injured, the "pathologic" spleen may have limited reparative capabilities. In this situation, operative management seems to be the safer therapeutic approach.

Laparoscopic-guided biopsy of pancreatic transplant allograft.

UNLABELLED: Percutaneous and transcystoscopic transplanted pancreatic graft biopsy have now become the best methods in diagnosing graft rejection and dysfunction. We report our technique of laparoscopic pancreatic graft biopsy in a case not amenable to standard trancystoscopic or percutaneous biopsy. CASE REPORT: A 44-year-old man underwent enteric conversion of a previous combined bladder-drained kidney-pancreas transplantation for repeated episodes of dehydration. Complaints of polyuria and polydipsia necessitated biopsies of the grafts to rule out graft rejection. The ultrasound of the pancreas, however, showed multiple bowel loops overlying the graft preventing percutaneous biopsy. The patient was taken for laparoscopic-guided pancreatic graft biopsy. DISCUSSION: Enteric-converted pancreatic grafts are not amenable to transcystoscopic biopsy. These grafts are often covered with loops of small bowel preventing ultrasound-guided percutaneous biopsy. Until recently, open laparotomy was performed to biopsy these grafts. We present our method of laparoscopic-guided pancreatic graft biopsy as an alternative to open laparotomy. CONCLUSIONS: Laparoscopic guided biopsy for pancreatic allograft transplantation is a safe and effective alternative to open laparotomy and should be considered when percutaneous biopsy is hazardous or not possible.

Massive intraperitoneal hemorrhage from traumatic intrasplenic pseudoaneurysms: treatment using superselective embolotherapy.

The importance of splenic preservation in the setting of penetrating and blunt trauma has led to the development of more sophisticated and noninvasive methods for controlling splenic hemorrhage. Although controversy exists, transcatheter embolotherapy has challenged the use of splenectomy in patients suffering from persistent bleeding after splenic trauma. We describe a case of a 41-year-old man with hepatitis C, ethanol-induced liver disease, and portal hypertension who presented with splenic rupture secondary to blunt trauma. Continued intra-abdominal hemorrhage was successfully controlled by superselective embolotherapy using microcoils and gelatin sponge pledgets.

Nutritional assessment and the role of preoperative parenteral nutrition in the colon cancer patient.

Hospital-based malnutrition is prevalent, especially among patients with gastrointestinal malignancy. Colorectal cancers produce malnutrition through impairment of gastrointestinal function and the liberation of cytokines. Malnourished patients who undergo operation have an increased likelihood of perioperative morbidity and mortality. The performance of a nutritional assessment will aid in the recognition of such patients and provide a risk assessment profile. Preoperative parenteral nutrition is a major expense and delays surgical intervention. Studies to document the efficacy of preoperative parenteral nutrition suffer from design flaws and small sample sizes. Studies that exclusively address patients with cancer of the colon and rectum are absent; therefore results must be extrapolated from the existing literature. Cumulative evidence suggests that a 7-10 day period of parenteral nutrition repletion in the severely malnourished patient will diminish the incidence of postoperative septic complications and mortality. The preoperative treatment of lesser degrees of malnutrition remain controversial. Once the decision has been made to institute preoperative parenteral alimentation, attention to the details of protein requirements and caloric needs should be stressed. The endpoint of therapy is poorly defined. The role of glutamine, arginine, omega-3 fatty acids, and growth hormone in the preoperative repletion process provide an exciting arena for future research.

Gastric intramural pseudocyst with associated gastric outlet obstruction: recognition and management.

Pancreatic pseudocyst is a well-recognized complication of pancreatitis. Most pseudocysts either resolve spontaneously or are amenable to internal drainage. Occasionally, the pseudocyst extends to distant areas within the abdominal cavity or may invade a nearby anatomic structure. Direct extension into the stomach is infrequently noted both radiographically and clinically. Recognition and management of this entity are described.

Splenic laceration secondary to closed chest massage: successful recognition and management--case report.

Closed chest massage can be a lifesaving act. Performed incorrectly or by untrained individuals it can lead to life-threatening complications. Successful recognition and treatment of a lacerated spleen secondary to cardiopulmonary resuscitation is reported. All patients surviving CPR should be screened for potential complications.

Competence statements for differentiated nursing practice in critical care.

The demand for high-quality patient care in the current complex health care environment and the variety of today's available nursing education programs dictate a need to differentiate nursing practice into technical and professional roles. These roles are based on competencies acquired in ADN and BSN degree programs and implemented in practice settings where the contributions of all nurses are valued. To create a preferred future, AACN has developed a model for differentiated nursing practice in critical care. The model is a guideline for those nurses and institutions who may be or will be involved in changing practice patterns. The model does not support or encourage the elimination or disenfranchisement of any individual or groups of nurses. These statements were developed to address specific behavior that reflects the valuable contributions of each category of nurses within critical care nursing. The statements provide a model for creating efficient and effective practice patterns that may contribute to high-quality outcomes for critically ill patients and their families.

Comparison of rejection rate and functional outcome of small bowel transplantation alone or in conjunction with the ileocecal valve versus combined small and large bowel transplantation.

Preservation of the ileocecal valve improves absorptive function and decreases the amount of small bowel needed for survival in patients with short gut syndrome. We compared the results of small and large bowel transplant (SLBTx), small bowel transplant only (SBTx), and SBTx with the ileocecal valve (ICVTx) in a porcine model. Total enterectomy was performed on 18 Yorkshire-Landrace pigs followed by orthotopic SBLTx (n = 6), SBTx (n = 6), and ICVTx (n = 6). A jejunostomy and an ileostomy were constructed for biopsies. Overall mean survival was 17 d with no statistically significant difference between groups. Rejection was seen in 6/6 SLBTx, 4/6 SBTx, and 4/6 ICVTx recipients. Acute rejection was seen in 84.3% of SLBTx, 52.3% of SBTx, and 42.5% of the ICVTx mucosal biopsy samples. Two cases of intra-abdominal infection were in the ICVTx group only. Weight loss was 147 g/d in the SLBTx group, 643 g/d in the SBTx group, and 393 g/d in the ICVTx group. While the functional outcome after SLBTx and ICVTx was noticeably better than the SBTx group, the increased rejection and intra-abdominal infection rates make transplanting the large bowel or the ileocecal valve a less attractive clinical option.