Role of thrombelastograph haemostasis analyser in detection of hypercoagulability following surgery with and without use of intermittent pneumatic compression.

The effect of using intermittent pneumatic compression on incidence of postoperative thromboembolic events was studied, and hypercoagulability following various kinds of surgery with or without use of intermittent pneumatic compression was evaluated with the use of a thrombelastograph. The study included 317 male patients undergoing various surgical procedures; 193 patients used intermittent pneumatic compression after surgery and 124 did not use intermittent pneumatic compression. Their ages ranged between 52 and 75 years. Thrombelastograph was used to detect hypercoagulability. Results showed that in patients using intermittent pneumatic compression, 67% of the hip surgery patients had hypercoagulability one to three days postoperatively, as did 34% having major thoracic or abdominal procedures and 18% in the remaining general surgery. Of 18 hip surgery patients who did not use intermittent pneumatic compression, 10 sustained thromboembolic complications following operation. Three deaths resulted from pulmonary embolism. For the remaining 106 patients who did not use intermittent pneumatic compression, seven patients manifested Deep venous thrombosis (DVT) and pulmonary embolism, and three deaths resulted from pulmonary embolism. There was no incident of thromboembolic complications for the 24 patients with hip surgery who used the intermittent pneumatic compression. There were no complications following various surgical procedures in the 169 patients who used intermittent pneumatic compression. It might be concluded that the thrombelastograph is useful to detect hypercoagulability postoperatively, and intermittent pneumatic compression is useful for thromboembolic prophylaxis.

Transmesenteric-transfemoral method of intrahepatic portosystemic shunt placement with minilaparotomy.

PURPOSE: To determine whether the transmesenteric-transfemoral method of intrahepatic portosystemic shunt (IPS) placement is safer and more efficient than the transjugular method. PATIENTS AND METHODS: Sixty-six consecutive patients with cirrhosis and bleeding varices underwent 67 IPS procedures. Sixty-one of these procedures were performed using a combination of transfemoral access to the hepatic vein with transmesenteric access to the portal system provided by means of minilaparotomy. Follow-up days were collected periodically by means of clinical evaluation and duplex sonography of the shunt. Angiographic evaluation was performed when necessary. RESULTS: No technical failures or periprocedural deaths occurred. The radiologic and surgical portions of the procedure were accomplished within 45 and 55 minutes, respectively. In cases without portal thrombosis, maximum fluoroscopy time was 12 minutes. During follow-up (mean, 16 months), eight shunt revisions including one additional shunt placement were necessary. CONCLUSION: Transmesenteric-transfemoral IPS placement requires surgical participation but may offer improved efficiency and safety compared with regular transjugular IPS placement.

Hepatic resections for primary and metastatic tumors using the ultrasonic surgical dissector.

We have previously described the development of new hepatic surgical techniques using the ultrasonic surgical dissector. With 10 years' experience, we have found that major liver resections have been simplified and that the technique is repeatable in hands other than our own. Thirty-three patients had 37 tumors, averaging 5.65 cm in size, resected with an average blood loss of only 1,020 mL per case, which included 5 right trisegmentectomies, 12 lobectomies, 15 segmental resections, and 4 subsegmental resections. Twenty-two patients had metastatic colorectal cancer. Blood transfusion requirements averaged only 2.24 units in long-term survivors, which was significantly less than the 3.5 units received by patients who have since died (p = 0.092). There were no operative deaths. The median survival of these 22 patients was 56 months, and the 5-year actuarial survival rate was 35%. All of the early deaths occurred in patients with more than four tumors, and no patient with less than four tumors died before 42 months with recurrent disease. Six patients had bilateral tumors, and the fact that patients survived into the fourth and fifth post-resectional year indicates that resection was worthwhile. All these patients had Dukes' C primary tumors, but we found no statistical difference in survival between patients with Dukes' B and Dukes' C lesions. The results indicate that hepatic resection with the ultrasonic surgical dissector decreases blood loss, requires few transfusions, is safe to perform, and is associated with excellent long-term survival.

Minimally invasive devascularization for variceal bleeding that could not be controlled with sclerotherapy.

The appropriate therapy for continued bleeding despite sclerotherapy remains controversial. This study evaluates a devascularization procedure performed without the risks of major surgery and general anesthesia. Fifty consecutive patients, each with an endoscopically proven variceal hemorrhage that was uncontrollable with sclerotherapy, were treated with minimally invasive devascularization. The procedure was performed in three stages. First, the portal pressure was sharply reduced by angiographic embolization of the midsplenic artery. Then the esophagogastric variceal network was thrombosed by means of a catheter introduced during laparotomy, which created a portoazygos disconnection. Finally, the left gastric and left gastroepiploic arteries were embolized, which completed devascularization of the proximal stomach. According to the Child classification, 16 patients were in class B and 34 were in class C. All Child's class B patients (16/16) and 71% (24/34) of Child's class C patients survived hospitalization. One-year survival was 94% (15/16) for Child's class B and 62% (21/34) for Child's class C patients. Rebleeding occurred in 63% (25/40) of the discharged patients but caused the death of only seven. In conclusion, the 20% initial hospital mortality for these difficult patients was significantly better than that reported for emergency surgery, and the rate of rebleeding was comparable to that seen with other nonshunting therapies.

The eleventh rib transcostal incision: an extrapleural, transperitoneal approach to the upper abdomen.

Subperiosteal resection of the eleventh rib with transcostal, extrapleural entrance into the retroperitoneum for exposure of the kidneys or adrenal glands has been well described in the urologic literature. We have used the incision with transperitoneal extension for various procedures in the upper abdomen. The following is a description of our operative technique with suggestions for procedures in which the incision may be used. The incision is ideal for splenectomy, distal splenorenal shunts, resections of the pancreatic body and tail, portacaval shunts, right hepatic lobectomy, and transperitoneal unilateral adrenalectomy.

Preliminary experience in liver surgery using the ultrasonic scalpel.

We will describe the development of new resectional techniques with the use of the ultrasonic scalpel in 33 patients with liver disease. Our experience is presented in the performance of anatomic and nonanatomic liver resections by use of this device. Its saline-cooled tip vibrated at ultrasonic frequencies and selectively fragmented target tissue, then suspended and aspirated the fragments, thus removing the mesenchyma from the blood vessels. Tactile feedback enhanced this dissection so that all but the smallest blood vessels could be divided between clamps or clips. This resulted in improved control and hemostasis in hepatic resections. Only six patients had complications and there was only one operative death. We now use this technique routinely as we believe it is a major advance over existing methods.

Myocardial function in acute pancreatitis.

Fifteen patients with acute pancreatitis had 68 physiologic cardiopulmonary assessments performed, and they were compared with 61 performed on normal postoperative patients, and 113 on 41 cirrhotics. It was found that the patients with pancreatitis have an elevated cardiac index (CI), which is not due to the hyperdynamic hemodynamic state found in cirrhotics. In spite of this, the Sarnoff curves demonstrated that pancreatitis was accompanied by a myocardial depression p less than 0.03, not found in hyperdynamic cirrhotics. Cirrhotics are unable to increase their oxygen consumption in response to an increase in CI, as do normal patients or those with acute pancreatitis. In cirrhotics the hemodynamic lesion occurs at the capillary level with the opening of arteriovenous shunts which rob the tissues of their nutritive blood supply, while the patient with acute pancreatitis has a primary myocardial depression and his peripheral vasculature reacts like that of a normal person.

Mobilization of trauma teams for aircraft disasters.

With more survivors of air crashes involving jumbo jets, an improved plan for life-saving emergency care at the crash site is discussed. The concept of airlifting predesignated Trauma Teams to the crash site from large medical centers within a radius of 100 miles is discussed. The "work-shop" for these teams is described in detail, providing an operating and intensive care facility at the scene of the disaster. It is shown how this kind of planning can be applied to natural disasters with multiple casualties as well as to airport disasters.

A five-year review of deaths following urban trauma.

At Metropolitan Hospital Center, New York City, 3,000 patients with trauma were admitted during 1974 through 1978, with a mortality rate of 4%. One hundred eight patients who were admitted and diet were analyzed. Ages were from 3 months to 84 years with clusters in 15-30 and 45-60 years. Injury Severity Scores (ISS) ranged from 9 to 66 (37). All body systems were equally represented. Most patients had two systems involved. Abbreviated Injury Scale (AIS) scores for most severe systems were 5 in 60%, 4 in 34% and 3 in 6%. Shock was present in 52%. Major complications; sepsis in 30% (pulmonary, 20%); neurological, 12%; respiratory failure 15%; renal failure 10%. Surgical care was optimal in 45%. In the remaining 55% at least one error occurred: inappropriate or inadequate fluid resuscitation, 37%; missed or delayed diagnosis, 20%; airway management, 10%; surgical judgment, 8%; surgical techniques, 9%. ISS scores, error/no-error; shock/no-shock, showed no significant differences. Patients with AIS scores of 3 were elderly or had errors in management. Management errors continue to be made in a significant number of severely injured patients, and may contribute to the demise of patients with survivable injury. These data parallel those reported to this society by van Wagoner (13) in 1960 and Foley in 1976 (5).

The myocardial depressant factor (MDF) in acute hemorrhagic pancreatitis.

Myocardial depression (measured by ventricular function curves on response to a fluid load) has been shown in 10 patients with acute hemorrhagic pancreatitis. Significant inadequate responses were found on evaluation of both the left and right heart. The increased pulmonary vascular resistance associated with adult respiratory distress syndrome (ARDS) of this disease was shown to correlate inversely with pulmonary wedge pressure, thereby excluding myocardial failure and pulmonary edema as mechanisms for the production of the ARDS.

B-mode ultrasound scanning in the diagnosis of renal lesions.

The use and value of a relatively new diagnostic modality, ultrasound, in the diagnosis of renal masses are discussed. Several examples are presented.