The effect of glucagon on hepatic cellular energetics during a low flow state.

An investigation of the effect of glucagon on liver high energy phosphate concentration during a low flow state is presented. Two groups of dogs were subjected to a 120-minute period of hemorrhagic hypotension followed by reinfusion of shed blood plus additional normal saline to restore the central venous pressure to 10 cm H2O. One group received glucagon intravenously in addition. Despite a significant increase in portal flow and oxygen delivery and a significant increase in liver glucose associated with glucagon administration, there was significant impairment in the ability of the liver to regenerate adenosine triphosphate (ATP). Evidence is presented to show the decreased ATP concentration was not related to hepatic blood flow, but was presumably due to increased catabolism.

Brain metabolism during increased intracranial pressure as assessed by niroscopy.

Intracranial pressure was increased in cats by infusion of "mock" cerebrospinal fluid into the cisterna magna. This condition was then treated by hyperventilation. In addition to direct measurement of intracranial pressure, cerebral metabolism was assessed by near infrared spectrophotometric (niroscopic) measurement of cytochrome a,a3 redox state and the quantity of reduced and oxygenated hemoglobin in the illuminated brain. Cerebral perfusion was assessed by injection of Cardio-Green. Increased intracranial pressure resulted in the expected reduction in cytochrome a,a3,a decrease in HbO2, an increase in Hb, and a reduction of blood flow. The vasoconstriction produced by hyperventilation, while reducing intracranial pressure, produced a further reduction in cytochrome a,a3 and HbO2, with no improvement in blood flow. The data illustrate the fallacy of governing therapy solely by intracranial pressure and demonstrate the need for a direct assessment of brain metabolism. The data also demonstrate the strengths and weaknesses of niroscopy as a noninvasive monitor of the brain metabolism if applied to patients at risk for increased intracranial pressure.

Concomitant pneumococcal appendicitis, peritonitis, and meningitis.

A 9-year-old boy developed pneumococcal meningitis and peritonitis following appendectomy. Subsequent pathologic examination showed Gram-positive diplococci in the appendix. Cultures of the peritoneal fluid, blood, and spinal fluid showed Diplococcus pneumoniae. The experience illustrates the danger of assuming that all pneumococcus peritonitis is the primary variety and the advisability of routine Gram stain of the peritoneal fluid at operation in order to select the appropriate antibiotic.

Emergent or elective operation for symptomatic abdominal aortic aneurysm.

The patient with the symptomatic abdominal aortic aneurysm (AAA) presents a management dilemma, ie, emergent, urgent, or elective operation. The mortality for 38 patients with a ruptured AAA prior to 1972 was 61%. That year, a policy of immediate operation was instituted for patients with symptoms that might be referable to a ruptured AAA. It is concluded that an immediate operation on the patient with a symptomatic but intact AAA resulted in an excessively high mortality. Thus, the indications for an immediate operation on these patients should be based on clinical judgment; attempting to differentiate between the patient with the ruptured and the patient with the intact aneurysm. Hemodynamic data (blood pressure hematocrit reading) suggesting a decrease in blood volume dictate an immediate operation. An urgent operation on the well-prepared patient should be performed on all patients with a symptomatic aneurysm in which the clinical and hemodynamic findings do not suggest that it has ruptured.

Biliary diversion for pancreatic carcinoma: matching the methods and the patient.

Two hundred eleven patients with adenocarcinoma of the pancreas were reviewed. Seventy had surgically constructed biliary-enteric anastomoses. Forty-two had percutaneous/endoscopic placement of biliary diversion catheters. Surgical biliary diversion was associated with discharge at 7 +/- 2 days postoperatively. Only five patients required subsequent reoperations for anastomotic failure secondary to continued tumor growth. Sixty-one percent of percutaneous/endoscopic catheters were associated with septicemia, and 27% occluded (average life span 36 days). Hospital days averaged 20 days of an average 64-day patient life span. After evaluation of computed tomographic scans and surgical findings, patients' diseases were arbitrarily divided into (A) local, (B) regional, and (C) distant spread. Survival was 417,300, and 53 days, respectively. In view of the morbidity associated with the percutaneous/endoscopic catheter, we recommend that its use be restricted to Group C patients.

Role of glucose-6-phosphate in cerebral dysfunction following hypoxia and hypotension.

Rats were "stressed" by a 30-minute period of breathing 7.5% oxygen combined with hemorrhagic hypotension (x arterial pressure = 25 mm Hg), and then "resuscitated" by restoring the inspired oxygen concentration to 30% and reinfusing the blood previously removed to produce hypotension. We have previously noted in initial return of brain adenosine-triphosphate to normal after this "stress" followed by a progressive decline during the post-resuscitation period. In this study, substrate deficiency was investigated as a possible etiology for the decreased adenosine-triphosphate. Glucose and glucose-6-phosphate concentrations in the brain were measured before "stress" and after resuscitation and were found not to change, indicating no deficiency of substrate.

Near infrared spectrophotometry: potential role during increased intracranial pressure.

Two experiments were conducted to assess the feasibility of near infrared spectrophotometry (niroscopy) to directly monitor the effects of increased intracranial pressure on brain metabolism. Intracranial pressure (ICP) was increased in cats by subarachnoid infusion of a "mock" CSF solution. Cytochrome a,a3 redox state, oxyhemoglobin, deoxyhemoglobin and cerebral blood flow were non-invasively and continuously monitored by niroscopy. The results of both experiments indicated that untreated increases in ICP correlated with a reduction in cytochrome a,a3 redox state (p less than 0.01), a decrease in the quantity of oxyhemoglobin and cerebral blood flow (p less than 0.01), and an increase in deoxyhemoglobin. This study suggests that niroscopy has the potential for providing noninvasively and continuously data assessing brain metabolic activity. The excellent correlations obtained with simultaneous direct measurements of intracranial pressure make this an attractive method for eventual application to humans at risk for increased intracranial pressure. The value of niroscopy is even more evident in Exp. II where it can be seen that knowledge only of ICP would give the physician a false sense of security, whereas direct, non-invasive, continuous assessment of brain perfusion and oxygenation may well prove to be more appropriate parameters to monitor.

Surgery for chronic pancreatitis: the tailored approach.

Considerable controversy exists regarding the optimal method of surgical relief of the pain of chronic pancreatitis. We previously made a retrospective study of 49 patients with chronic pancreatitis who were operated upon only for relief of pain. Those results indicated that patients who had an internal decompression had lower mortality, less morbidity, less postoperative pancreatic insufficiency, and better relief of pain (88% vs 76% improved). Since then, we have prospectively determined the operative treatment based upon the criteria outlined in that previous report. Seventeen patients had 19 operations (12 resections, seven internal drainage procedures). The patients' ages, duration of symptoms, and sex distribution are similar. Eight-five percent of patients with internal decompression had good to excellent relief of pain vs 60% of patients with resection. Pancreatic insufficiency occurred in 70% of patients who had resection and in only 14% of those who had drainage. Forty percent of patients who had resection had mild to severe postoperative morbidity vs 14% of those who had drainage. There was one postoperative death in the resection group. These preliminary results indicate that internal decompression in properly selected patients can provide superior relief of pain, with lower mortality, less morbidity, and less pancreatic insufficiency.

Pancreatic and duodenal injuries: morbidity and mortality of surgical management.

A retrospective review of pancreatic injury is presented. Twenty-five cases in which the pancreatic injury was either the sole or major injury were selected from over 100 cases of pancreatic injury admitted during the period 1970 to 1977. Eight pancreatic injuries resulted from blunt trauma and 17 from penetrating trauma. Two methods of treatment were compared, drainage alone versus duodenal diverticularization and/or distal resection. There were no deaths. Of the 15 patients treated by drainage alone, 14 (93%) developed postoperative complications, as compared to 20% (two of ten patients) treated by diverticularization and/or distal resection.

Factors limiting extremity function following vascular injury.

The clinical management of 47 patients with vascular injuries of the extremities is presented with emphasis on functional results. The method of restoration of vascular continuity or the presence of associated fractures or venous injury had little bearing on either the success of arterial repair or functional result. The most significant factor adversely affecting restoration of extremity function was the presence of associated major proximal nerve injury.