Chylous ascites: a rare complication of vagotomy. Case report.

A previously healthy 30-year-old man underwent vagotomy and pyloroplasty for a chronic duodenal ulcer that had not responded to H2 blockers. On the third day his abdomen was slightly distended; this gradually increased and on the eighth day ascites was confirmed by ultrasonography. Paracentesis yielded 4 litres of milky, odorless fluid. He was treated by fat free diet as he refused parenteral nutrition and on day 15 a further two litres of fluid were withdrawn, this time straw coloured. By day 31 his abdomen had returned to normal and his serum albumin concentration (which had dropped to 26 g/l) had risen to 43 g/l. He has now remained well for two years. Chylous ascites is a rare complication of truncal vagotomy, but should be suspected if postoperative ascites develops. Early recognition and treatment are important.

Portal hypertension complicating abdominal tuberculosis. Case report.

Two cases of abdominal tuberculosis complicated by portal hypertension are reported. Both presented with haematemesis, melaena, night sweats, anorexia and weight loss. Tuberculous lymph nodes at the porta hepatis compressed the portal vein in one case, and the other had disseminated tuberculosis involving the liver and spleen. The mechanism of such portal hypertension is discussed.

Intermittent intra-aortic balloon tamponade during hemorrhagic shock.

The use of intermittent intra-aortic balloon tamponade was evaluated during resuscitation of hemorrhagic shock in a sheep model. Twenty adult sheep were exposed to severe hemorrhagic shock and they were all treated with crystalloids (8% of body wt) during one hour. Ten of these were also treated with intermittent supraceliac intra-aortic balloon tamponade during the initial 30 min (group A) while the other 10 were used as a controls (group B). In the group treated with intra-aortic tamponade the mean arterial pressure (MAP) was rapidly increased as the balloon was inflated, but it dropped to the same level as in the control group during deflation. In this group there were also great fluctuations in systemic vascular resistance (SVR), pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) when the aortic balloon was inflated/deflated, while central venous pressure (CVP) and pulmonary capillary wedge pressure (PCWP) were hardly affected at all. After final deflation of the aortic balloon (at 30 min), MAP remained 35% lower than the baseline value (p less than 0.01), similar to the control group. Cardiac index (CI) increased continuously during the first 30 min, at which time it reached the pre-shock level in both groups. At the end of the resuscitation period there was no significant difference between the two groups in any of the cardiovascular parameters measured. Four animals died in group A and 3 in group B within 24 hours, after which time the survivers were sacrificed. Both groups had high incidence of pathological changes in the kidneys, liver, intestine, and lungs. Six animals in group A had hind limb paralysis and loss of anal sphinter tone after the resuscitation. It was concluded that intermittent supraceliac aortic occlusion for 30 minutes did not decrease morbidity or mortality in sheep exposed to severe hemorrhagic shock compared with a control group treated in a traditional way with fluid replacement.

Hydatid liver disease: problems in diagnosis in the Middle East endemic area.

Imaging techniques such as ultrasound (US), liver scan and computerized tomography (CT) localize mass lesions in the liver and abdomen, and are valuable tools in the differential diagnosis of hydatid disease. However, we present two cases from Kuwait in the Middle East which demonstrate that these techniques alone are not as accurate as claimed in this geographical area. A sensitive and specific serological test is essential for a pre-operative diagnosis of hydatid disease. Discrepancies between radiological imaging and serological diagnosis are best resolved by cytology of the drained fluid and/or histopathological examination of the excised cyst. Negative serology would indicate ultrasound-guided aspiration of cyst fluid for cytological verification or enzyme immunoassay.

Intraaortic balloon tamponade during hemorrhagic shock in sheep.

Two groups (n = 10 in each) of adult sheep were exposed to hemorrhagic shock resulting in mean arterial pressure (MAP) below 25 mmHg for 10 min. Following that, group A received crystalloids (8% of body wt) during one hr together with supraceliac intraaortic balloon tamponade during the first 30 min, while group B (controls) received crystalloids only. The central circulation was rapidly restored in group A, as indicated by increased MAP and increased systemic vascular resistance (SVR). After deflation of the balloon MAP dropped to the same value as in the control group, while cardiac index increased gradually with volume replacement and was significantly higher at the end of the resuscitation period (60 min) than in the control group (P less than 0.05). Despite a more rapid restoration of central hemodynamics in group A, lactic acidosis was more severe, acute renal failure and neurological complications more frequent, and mortality higher than in the control group. It was concluded that continuous supraceliac aortic occlusion for 30 min had deleterious effects on organs dependent on aortic blood flow distal to the aortic tamponade and may contribute to the development of multiple organ failure after resuscitation from hemorrhagic shock. Further studies are needed to evaluate the effects of intermittent intraaortic balloon tamponade in hemorrhagic shock.

Splenic implants: evaluation with radionuclide methods.

The viability of omental splenic implants placed in 16 patients who had undergone splenectomy was assessed with 37 technetium-99m tin colloid studies and five studies with Tc-99m-labeled denatured red blood cells (RBCs). Indications for splenectomy included trauma in eight patients, schistosomal (Bilharzial) portal hypertension in six, splenic artery aneurysm in one, and Wiskott-Aldrich syndrome in one. Studies were done within the 1st month and at various intervals up to 13 months after surgery. Implants in five of eight trauma patients were seen during the 1st month, and implants in seven of seven were seen after 6 months (one patient could not be followed up). Three of six implants in cases of portal hypertension were seen in the 1st month and four of four at 6 months (two patients were not followed up). In two of the five studies with denatured RBCs, Tc-99m tin colloid study was also done 48 hours later; in these cases denatured RBCs were more successful in showing the implants. The authors conclude that radioisotopic procedures are valuable in following up the viability of splenic implants. The "take" of splenic implants in patients with schistosomiasis is equally successful to that in trauma patients.

Hepatobiliary imaging after Whipple's operation.

Hepatobiliary imaging after Whipple's operation provides information regarding the flow of bile. In the case presented there was jejunogastric bile reflux. This demonstrated the incompetence of the side to side jejunojejunostomy, which was surgically recommended to avoid bile reflux to the stomach. Jejunogastric bile reflux explains the patient's complaint of dyspepsia and occasional bilious vomiting in this case.

Popliteal artery injury in Kuwait.

While there is an abundant literature on popliteal artery injury secondary to penetrating trauma, few reports deal with popliteal artery injury caused by severe blunt trauma with or without fracture. Eight cases of popliteal artery injury are described. Seven of the patients had sustained blunt trauma, usually resulting also in damage to bone and soft tissues. The popliteal vein was involved in five of the injuries. The time lag between causal trauma and vascular repair averaged 25 hours. Delay was due mainly to failure to consult the vascular surgeon at an early stage. Leg amputation was necessary in two cases. Two patients died. The importance of early recognition of the vascular injury and appropriate surgical measures was illustrated in this small series of patients from a developing Middle Eastern country. Adequate fasciotomy, venous repair, use of intraoperative Doppler and repeated postoperative débridement are discussed in connection with management.