Aspirin improves the patency rate of seeded vena cava grafts.

The purpose of this study was to evaluate the effectiveness of aspirin (ASA) and porcine endothelial cell seeding in improving the patency rate of vena cava grafts. Thirty-nine dogs underwent infrarenal vena cava replacement by 10 cm lengths of 8 mm I.D. ringed polytetrafluoroethylene grafts. Thirty-one grafts were seeded with 1-1.5 x 10(6) porcine aortic endothelial cells while eight were not (GIII). Of the seeded group, 16 animals received no ASA (GI), while 15 others (GII) were given ASA (325 mg) daily starting two days preoperatively and continuing until sacrifice. Venograms were performed on the fourth postoperative day. Grafts were harvested 32 days after insertion and evaluated for patency rate and endothelialized surfaces. The 32-day patency rate was significantly higher for GII than for GI and III animals (67% vs. 13 and 25% respectively). Endothelialized surface was higher in GII than Gi and III (67% vs. 16% and 18% respectively). We conclude that endothelial cell seeding alone does not prevent graft closure and that a combination of ASA and cell seeding significantly increases the patency rate of vena cava grafts.

Effect of preclotting and precoating agents on seeded venous grafts.

This study evaluated the effect of whole blood preclotting (WB), fibronectin (FB) and "Cell Tak" (CT) precoating on the patency rate of seeded vena cava grafts. Ten cm x 8 mm ID ringed PTFE grafts were implanted in the vena-cavae of 29 dogs. Aspirin (325 mg po qd) was administered pre-operatively and continued post-operatively. After preclotting or precoating, all grafts were seeded with porcine endothelial cells. The 32 day patency rates were: 67%, 67% and 37% for WB, FB and CT, respectively (p less than 0.5 CT vs FB, WB). Endothelialized surfaces ranged from 67 +/- 35, 43 +/- 41 to 28 +/- 45% respectively for WB, FB and CT (p less than 0.05 CT vs WB). Preclotting time was shortest for WB technique. We conclude that: 1) FB and WB grafts have the highest patency rate with WB preclotting being a more cost effective and less time consuming technique; 2) endothelial seeding and Aspirin may make vena cava grafting possible.

Effect of hepatectomy on the reticuloendothelial system of septic rats.

The purpose of this study was to evaluate the function of the reticuloendothelial system (RES) of sham hepatectomy and 20% and 50% partial hepatectomy (PH 20%, PH 50%), with or without cecal ligation and puncture-induced sepsis. The animals were injected with 51Chromium sheep red blood cells (SRBC) at 72 hours. SRBC half life (T1/2) was measured as an index of RES function and the percentage distribution of SRBC in liver, lung, and spleen was calculated. T1/2 was significantly prolonged in PH 50% rats and was associated with decreased radioactive uptake by the liver. Mortality was nil in the control groups and markedly increased in the presence of sepsis. The results suggest that decreased RES function following hepatectomy is dependent upon the proportion of liver removed and that sepsis further increased the mortality of hepatectomized animals.

White clot syndrome.

Heparin therapy is currently a vital component in the medical management of thromboembolic events. Despite its widespread use, it is associated with relatively few complications, and these are usually minor and quickly reversible. Recently a much more dramatic and serious complication of heparin therapy has been identified. In heparin-induced thrombocytopenia with associated thrombosis or "white clot syndrome," patients have paradoxic thromboembolic events while receiving heparin. These events are of acute onset and of major consequence, often resulting in limb loss or death. This paper describes our own experience with ten patients in whom the white clot syndrome occurred during heparin therapy for thrombotic or embolic events. Both porcine and bovine heparin preparations were being given through various routes. In the three cases in which platelet aggregation testing was completed, results were positive. Our ten patients ultimately had a 20% major limb amputation rate and an overall 50% mortality.

Thoracic outlet syndrome: a comprehensive evaluation.

Using various modalities, 480 patients were evaluated for thoracic outlet compression syndrome. Of this group, 300 patients were eventually diagnosed as having thoracic outlet syndrome after extensive evaluation. Ninety of these patients underwent a total of 103 operative procedures for thoracic outlet decompression. Nerve conduction velocities and directional Doppler studies were the most useful adjuncts in making the diagnosis. Surgical therapy after proper selection yielded an 80.6 per cent long-term "good" operative result and an additional 6.9 per cent long-term "fair" operative result in follow-up to 12 years.

Triple lumen catheters for parenteral nutrition.

We retrospectively reviewed the charts of 61 patients in whom a total of 101 triple lumen catheters (TLCs) were used for parenteral nutrition for a total of 1,512 days (mean 15 +/- 11 days). Patients were categorized as those having culture-negative TLC tips either with or without infection elsewhere (groups 1 and 2, respectively) and those with culture-positive TLC tips (group 3). Temperature, WBC, alkaline phosphatase value, and SGOT level were recorded one or two days before TLC removal (period 1) and one or two days or three to five days after TLC removal (periods 2 and 3, respectively). The incidence of catheter sepsis was 4%. Fourteen other tips were contaminated. Patients in group 1 remained afebrile during all three periods, and all tips removed were culture-negative. Removal of the TLC in groups 2 and 3 caused neither defervescence nor decreased WBC. We conclude that TLCs can be used for total parenteral nutrition with a low incidence of infection, that TLC tips need not be cultured in afebrile patients without other sources of infection, and that a TLC can be safely left in place so long as the patient is afebrile. However, the risk of infection or contamination is high for catheters left in place for more than two weeks.

Effects of postoperative carbohydrate overfeeding.

Forty-three indirect calorimetric studies were performed on 24 patients who received postoperative supplemental nutrition for a total of 1088 days. Patients were retrospectively grouped into Group 1 (G1) (respiratory quotient greater than 0.95) and Group 2 (G2) (respiratory quotient less than 0.95). The two groups had similar preoperative biochemical values, prognostic nutritional index, nitrogen intake and excretion, predicted resting energy expenditure and caloric intake. Minimal postoperative biochemical changes were noted between the two groups. Postoperative length of stay was longer for GI than GII patients (P = NS). However, septic episodes and mortality were higher (100% vs 40% and 28% vs 10%, P greater than 0.05), respectively, in G1 than in G2 patients. It is concluded that carbohydrate overfeeding may be associated with a high morbidity and mortality.

Peripheral arterial missile embolization: a case report and 22-year literature review.

The present case report is that of an air pistol missile injury with perforation of a common femoral artery and subsequent arterioarterial embolization to the anterior tibial artery. Included in this report is a review and analysis of a 22-year experience in the vascular trauma literature with missile injuries resulting in cardioarterial or arterioarterial embolization. In-depth analysis of this collective literature review revealed small weapon caliber (79%), usually .22. Soft tissue tamponade at the injury site in the form of mediastinal hematoma, retroperitoneal hematoma, or hemopericardium preventing exsanguination occurred in 37% of cases. Cardiac and thoracic aortic entry sites represented 70% of the series with distinct patterns of peripheral vascular embolization found resulting from anatomic relationships and laminar flow. Diagnostic evaluation by means of remote x-ray screening documented 86% of the emboli and was supplemented with arteriographic studies in 36%. Direct transverse arteriotomy overlying the projectile was favored; most of the delayed embolectomies stemmed from a failure to recognize those patients with peripheral embolization and a compensated asymptomatic limb. An appropriate management plan and diagnostic algorithm for this rare vascular phenomenon have been generated by this study.

Management of intra-abdominal lymphomas.

Fifty-nine patients (mean age 65) were evaluated for intra-abdominal lymphomas, localized or disseminated, during the period between 1977 and 1985. These lymphomas were lymphocytic (66%), histiocytic (17%), follicular (10%), and mixed (7%). Liver and retroperitoneal nodes were most frequently involved (32%), followed by stomach (31%), bowel (17%), and spleen (20%). Thirty-five patients (59%) underwent some type of surgical procedure supplemented by either chemo- or radiation therapy. Curative and palliative resections accounted for 40 per cent and 26 per cent, respectively while diagnostic laparotomy with or without staging accounted for 34 per cent. The 1-month postoperative mortality was 20 per cent. The 5-year survival was 12 per cent for the surgical group and 0 per cent for the medical group (P less than 0.05). Patients with lymphomas of the stomach and spleen, treated surgically, fared better than their medical counterparts. Most patients in this series died of their disease (55%) or from attempts to eradicate it.

Effects of altered portal hemodynamics after distal splenorenal shunts.

Patients with cirrhosis who had undergone the distal splenorenal shunt were grouped based on preoperative to early postoperative changes in hepatic portal perfusion and corrected sinusoidal pressure. Early and late postoperative morbidity and mortality rates were determined for each hemodynamic group. Morbidity was least when both hepatic portal perfusion and sinusoidal pressure were maintained near preoperative levels (Group 1). Survival for this group was significantly better than for patients who lost portal flow to the liver during the early postoperative interval (Group 4). Patients with absent hepatic portal perfusion had the worst survival and greatest morbidity. Intermediate results were achieved for the two groups of patients that had postoperative preservation of portal perfusion but significant preoperative to postoperative alterations in sinusoidal pressure. Although survival curves for these two groups were not significantly different from Group 1, morbidity was greater, especially for patients with an increase in sinusoidal pressure (Group 2).

Infections of the lower extremities due to gas-forming and non-gas-forming organisms.

From 1977 to 1984, 87 above- and below-knee amputations were done on 77 patients for ischemic ulcerations and gangrene of the lower extremities. The overall three-month mortality was 14% and was mainly related to generalized atherosclerosis. Patients having infections with gas formations were more likely to be diabetic (80% vs 15%, P less than .01), have clinical sepsis and a higher preoperative WBC (19,000 vs 12,600/cu mm, P less than .01), and have a higher mortality (40% vs 12%, P less than .05) than those with infections due to non-gas-forming organisms. Mixed bacterial flora were cultured from most wounds. We conclude that infections with gas formation may be due to either clostridial or nonclostridial organisms, mortality is higher if gas accumulates and if the patient is diabetic, gas is more likely to accumulate in infected extremities of diabetic patients, and the combination of gas formation and diabetes is highly lethal.

Splanchnic hemodynamic changes after the distal spleno renal shunt.

Marked changes in preoperative to postoperative corrected sinusoidal pressures (CSP) occurred in 51 per cent of a series of 51 patients undergoing the distal splenorenal shunt. Twenty patients who had the highest incidence of partial portal vein thrombosis, (48%--Group I), showed minimal pre- to postoperative changes in CSP. Twelve patients (Group II) who increased their CSP to 4 mm Hg or greater had marked postoperative hyperbilirubinemia and decreased portal blood flow. Fourteen patients who decreased their CSP 4 mm Hg or more postoperatively also showed moderate portal blood flow decrease without significant changes in liver enzymes. Morbidity and mortality were not significantly different among the three groups. The significance of these hemodynamic changes is not known.

Automated respiratory monitoring in sepsis.

The automated respiratory profile allows rapid computation of all the various pulmonary parameters, hence early diagnosis of A.R.D.S. in patients prone to develop that syndrome, as well as sequential follow-up of progression of pulmonary disease. Extubation is unlikely in patients whose (A-a) DO2, QS/Qt, and VD/VT remained higher than 500 mm Hg, 25% and 0.6 respectively.

Hyperbilirubinemia following distal splenorenal shunt.

To assess the incidence, pathogenesis, and associated morbidity and mortality of hyperbilirubinemia following the distal splenorenal shunt, hepatic hemodynamics, liver function, and clinical course were evaluated before and after this procedure in 78 cirrhotic patients. Individuals with a peak postoperative bilirubin level greater than 5 mg/dL had a higher preoperative bilirubin concentration, worse Child's score, longer hospital stay, and higher mortality than patients with a peak postoperative bilirubin level less than 5 mg/dL. Mean preoperative and postoperative hepatic portal perfusion and sinusoidal pressure were similar in both groups. When only patients with minimally elevated preoperative bilirubin levels (less than 2 mg/dL) were analyzed, 83% of individuals who developed postoperative hyperbilirubinemia (level, greater than 5 mg/dL) had a major alteration in hepatic hemodynamics as manifested by either complete portal vein thrombosis or a marked change in sinusoidal pressure (greater than 4 mm Hg). Although preoperative hepatic functional reserve is the major determinant of postoperative bilirubin concentration, alterations in hepatic hemodynamics secondary to the distal splenorenal shunt may also play a role.

Automated immune profile.

A simple means of evaluating the immune function of critically ill patients has been designed. This system uses 22 input data that are derived from an assessment of humoral and cellular immunity and of the various factors known to influence the immune status. The profile allows quantification of the degree of immune depression as well as follow-up of the progression of the immune status.

Gunshot wounds to the buttocks.

Twenty patients sustaining gunshot wounds (GSW) to the buttocks (including one shotgun wound) were treated at two affiliated institutions during the last 5 years. Male patients predominated nine to one. Fifteen patients with extraperitoneal injuries had a benign course. One underwent negative exploratory laparotomy based upon positive physical findings. The remaining five patients had clinical abdominal findings consistent with severe intra-abdominal injuries (four organs per patient). Although the morbidity was high, there was no mortality in this series. Careful analysis of a bullet's trajectory will allow detection of a possible intraabdominal component of this type of injury, mandating early surgical management.