Glucose-insulin response to oral glucose in a healthy obese population.

The characteristics of the glucose and insulin responses during the glucose tolerance test (GTT) in obese people as a group have not been established. We analyzed glucose and insulin levels during GTT in 160 healthy obese patients who averaged 42% over ideal body weight. Statistical upper limit of normal for 2-h glucose was 260 mg/dl in women and 206 mg/dl in men. Although there was a significant correlation between insulin and glucose levels in both sexes and between insulin and degree of obesity in women, r values were relatively low (r less than 0.4 for all). High insulin levels and delayed peak insulin were present in the majority of patients with normal GTT and absent in many of the most obese patients. Results indicate that upper limits of normal glucose for GTT in the obese are much higher than currently accepted criteria.

Survival and function after left ventricular aneurysmectomy.

Operative and late postoperative results in 55 patients undergoing resection of a discrete, saccular type left ventricular aneurysm are described. All patients had occlusive lesions of either the left anterior descending or left main coronary artery, and 72 per cent had significant multivessel disease. Preoperative factors that correlated significantly with decreased long-term survival were age greater than 60 years, severe congestive heart failure, and subnormal cardiac output at rest. The primary determinant of long-term postoperative survival appears to be the functional state of residual myocardium after aneurysmectomy. The survival rate for patients with multivessel disease was not less than that of patients with isolated lesions of the left anterior descending coronary artery. The impact of simultaneous aorto-coronary bypass grafting on postoperative results in patients with multivessel coronary disease is discussed. An advantage to concomitant revascularization with aneurysmectomy cannot be statistically corroborated in this series. However, improvement in results since the routine application of bypass grafting in appropriate cases, the uniform operative survival of bypassed patients with triple vessel disease, and the relatively high frequency of myocardial infarction as a cause of late postoperative death suggest that bypass grafting in patients with multivessel disease should be combined with aneurysmectomy to maximally improve long-term prognosis.

The significance of asymptomatic unilateral carotid bruits in preoperative patients.

The significance of asymptomatic carotid bruits was evaluated in patients undergoing major vascular operative procedures. A retrospective analysis of 588 patients was performed. Ninety-two patients (15%) had unilateral carotid bruits detected on admission examination. None had had cerebrovascular symptoms. Four postoperative strokes occurred in the total group of 588 patients. All occurred in patients without bruits. There were no permanent or transient postoperative neurological deficits in the group of patients with asymptomatic unilateral carotid bruits. We can find no data to support the necessity for preoperative carotid arteriography and endarterectomy in the patient with an asymptomatic carotid bruit prior to undergoing a major operative procedure.

Use of the EEA stapling instrument for control of bleeding esophageal varices.

Transection of the esophagus with the EEA stapling device (United States Surgical Corp.) has been used to treat 20 patients with bleeding esophageal varices. Their ages ranged from 38 to 73 years (mean 56.7 years). Sixteen patients (80%) had Laënnec's cirrhosis. A previous occluded portosystemic shunt was present in five patients. Based on Child's classification, there were one class A patient, 18 class C patient, and one patient who was unclassified. Five patients underwent elective operation; four survived (80%). The cases of the remaining 15 patients were treated as emergencies or semiemergencies after intensive preoperative intervention including intravenous administration of vasopressin (Pitressin) (100%), balloon tamponade in 11 (73%), and sclerotherapy in three (20%) failed to control the hemorrhage adequately. None of the patients had rebleeding from varices during the postoperative period. However, 11 of the 15 patients (73%) died. All deaths were related to liver failure, except for two patients who died of irreversible acidosis secondary to shock. Technical difficulty was encountered six times with use of the stapling device, resulting in three perforations of the esophagus, which were recognized and repaired at the time. No deaths were attributed to this complication. Of the eight patients who survived the early postoperative period, three have since died--two of variceal hemorrhage and the other of hepatic failure. Two others have had recurrent variceal hemorrhage controlled by sclerotherapy. The duration of follow-up ranges from 10 to 60 months (mean 31 months). Transection of the esophagus with the EEA stapling device for acute variceal hemorrhage is associated with an excessively high mortality rate despite the fact that it controls variceal hemorrhage. It appears to be of value when used on an elective basis for selected patients who cannot benefit from other modes of treatment.

Correction of hypersplenism following distal splenorenal shunt.

The effect of splenorenal shunt on hypersplenism was assessed in 47 patients with splenomegaly, 26 of whom had significant thrombocytopenia or leukopenia. Of 16 patients with thrombocytopenia, platelet count returned to normal in 15 (94%) following operation, an improvement which was statistically highly significant (P less than 0.001). Of 16 patients with leukopenia, leukocyte count returned to normal in 11 (69%), also a highly significant improvement (P less than 0.001). Dramatic relief of hypersplenism occurs in the majority of patients following splenorenal shunt. Thrombocytopenia is more consistently corrected than is leukopenia. The etiology of liver disease appeared not to be a factor, but leukopenia was corrected more consistently in alcoholic than in nonalcoholic patients, while there was no difference in the postoperative response of thrombocytopenia to the operation. Long-term follow-up in 26 patients demonstrated sustained improvement in 57% of patients with preoperative leukopenia and 78% of patients with thrombocytopenia. Since significant improvement in leukopenia and thrombocytopenia will occur following the distal splenorenal shunt, hypersplenism is not a contraindication to this procedure.

Cardiovascular risk factors in patients with peripheral vascular disease.

Cardiovascular risk factors in 566 patients with peripheral arterial disease undergoing major vascular operations were analyzed by chi-square analysis. There were 37 postoperative deaths, for a mortality rate of 8.5%. Cardiovascular complications were responsible for 23 deaths (62%). Five risk factors--congestive heart failure, prior myocardial infarction, prior stroke, arrhythmia, and abnormal electrocardiogram--showed significant individual associations with postoperative cardiovascular complications. A multivariate analysis of these five risk factors and angina led to the development of an equation which predicts the probability of a postoperative cardiovascular complication. The number of complications observed corresponded closely to that predicted by the equation. There was a significantly higher incidence of complications in patients predicted to be at high risk than in those at low risk.

Observations on fifty distal splenorenal shunts.

Fifty patients underwent conventional distal splenorenal shunts for bleeding esophageal varices. Five patient died within 30 days, giving an operative mortality of 10%. Three patients were lost of follow-up, but 47 patients were evaluated. Twelve patients died, 11 of liver failure, with more than half of the deaths occurring with 1 year, three fourths within 2 years, and all within 3 years after operation. Eleven patients rebled, and seven of these were among those who died. Sixteen patients had ascites prior to operation, but all responded to aggressive medical therapy. Twenty-two patients were available for study 2 or more years following operation. Eighteen (82%) are well with no encephalopathy, although the remaining four (18%) have had transient episodes of encephalopathy. Sixteen of the 18 patients judge their lifestyles to be productive. If the patient survived 24 months or longer, he had a four in five chance of living a normal life.

Idiopathic acute pancreatitis: the value of endoscopic retrograde cholangiopancreatography.

Acute pancreatitis is classified as idiopathic when an underlying cause cannot be identified through a careful history and appropriate noninvasive tests. Unless a cause can be identified, recurrent attacks cannot be effectively prevented. Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 35 patients considered to have idiopathic recurrent acute pancreatitis, and an anatomic abnormality of either the pancreatic or biliary ductal system was demonstrated in 16. Ten underwent appropriate surgical procedures based on the results of ERCP, and 80% had no further episodes of acute pancreatitis. ERCP established the precise nature of potentially correctable anomalies and thereby facilitated precise preoperative planning. The wider use of ERCP in these patients may lessen the number of cases of acute pancreatitis considered to be idiopathic and lead to appropriate surgical therapy.

Determination of viability of ischemic intestine by Doppler ultrasound.

Doppler ultrasound was used to determine the viability of ischemic small intestine and to select the optimum point for resection of nonviable bowel. Twenty ischemic segments of small intestine were produced in dogs by ligating the vascular supply. The Doppler ultrasound probe then was used to determine the last point of arterial flow within the bowel wall. The dogs were reexplored after 24 hours. Histological examination of full-thickness biopsies showed the intestine to be normal in all 20 segments at the last audible Doppler signal, and in 19 of the 20 segments at 1 cm distal to the last signal. Progressive degrees of necrosis were observed at 2 and 3 cm distal to the last signal. Twenty-five segments of ischemic intestine were resected in baboons. All resections performed at the last Doppler signal or 1 cm distal to it were normal 1 month later. Of 15 resections performed at 2, 3, and 4 cm distal to the last signal, 10 showed evidence of stricture or anastomotic disruption. Doppler ultrasound is a reliable method for determining the viability of ischemic intestine and for selecting the optimum point for resection of nonviable bowel.

Significance of asymptomatic carotid bruits.

To assess the significance of the asymptomatic carotid bruit, the subsequent occurrence of symptomatic cerebrovascular insufficiency and stroke in 256 patients who had undergone operation for atherosclerosis arterial occlusive disease of the lower extremities was documented during a period of two to seven years postoperatively. At the time of operation, none had had a stroke or exhibited symptoms of cerebrovascular insufficiency, but 60 of the 256 patients had audible carotid bruits. A statistically significant difference was demonstrated: 21 (35%( of the 60 patients with carotid bruits exhibited manifestations of cerebrovascular insufficiency, in contrast to 30 (16%) of the 196 patients without bruits. It seems that detection of an asymptomatic carotid bruit is not an innocent finding, but rather predicts a higher incidence of cerebrovascular complications than that expected on the basis of generalized atherosclerosis alone.

Intraoperative localization of intestinal arteriovenous malformation.

Intestinal arteriovenous malformation (AVM) is an uncommon cause of gastrointestinal hemorrhage and is difficult to diagnose. Selective visceral angiography is essential to make the diagnosis and to localize the lesion. We treated two patients in whom AVMs of the small intestine were located by means of arteriography and intraoperative selective mesenteric venous pressure and PO2 measurements. The local venous return from an intestinal AVM is characterized by elevated venous pressure and PO2 levels compared with the venous drainage of adjacent normal intestine.

Endoscopic retrograde cholangiopancreatography. Its use in the evaluation of nonjaundiced patients with the postcholecystectomy syndrome.

Forty-two patients with the postcholecystectomy syndrome were studied by endoscopic retrograde cholangiopancreatography (ERCP). Both the biliary ductal system and pancreatic duct were well visualized in all patients. The ERCP was abnormal in 22 patients (52%). Abnormal findings included choledocholithiasis, papillary stenosis, pancreas divisum, pancreatic carcinoma, sclerosing cholangitis, incomplete cholecystectomy, and chronic pancreatitis. The results of one or more standard liver function tests and/or other noninvasive tests were abnormal in 36 patients; however, none reliably predicted the presence or specific anatomical type of pancreaticobiliary tract disease. Our data indicate that ERCP is essential in the diagnosis and management of the postcholecystectomy syndrome. The high yield of abnormal findings amenable to surgical correction in patients with recurrent biliary tract symptoms following cholecystectomy justifies the use of this procedure in all such patients.

Hippocampal cholinergic alterations and related behavioral deficits after early exposure to ethanol.

The present study was designed to ascertain septohippocampal cholinergic alterations and their related behavioral deficits after early exposure to ethanol. Mouse pups were exposed to ethanol, 3 g/kg by daily subcutaneous injection on postnatal days 2-14. At age 50 days, the ethanol-exposed mice had significant reductions from control levels in eight-arm maze performance. For example, on the fourth testing day, the number of correct entries in the ethanol group was 21% below control levels (P < 0.05) and the number of trials needed to enter all arms was 48% above control (P < 0.001). It took the ethanol-exposed mice twice the time to reach criterion than it did control (P < 0.01). A 33% increase from control level in muscarinic receptor number (Bmax) was found in the treated mice of age 22 days and a 64% increase at age 50 days (P < 0.001). However, no differences between control and treated groups could be detected in the presynaptic component of the cholinergic innervation, choline acetyltransferase activity. The results suggest that early ethanol exposure acts on hippocampal function similarly to phenobarbital, probably via alterations in postsynaptic processes in the septohippocampal cholinergic pathways.

Acute pancreatitis in elderly patients. Pathogenesis and outcome.

Forty patients over 70 years of age with acute pancreatitis were studied. The most common cause of pancreatitis was biliary tract disease (14 patients, 35 percent). Twelve patients (30 percent) were discharged with a diagnosis of idiopathic pancreatitis, but tests such as endoscopic retrograde cholangiopancreatography that might have established the cause of disease were frequently not employed. Eight of the 40 patients died, for a mortality rate of 20 percent. Significant morbidity occurred in an additional seven (17.5 percent). Multisystem failure was the cause of death in all eight patients, and only two patients with multisystem failure survived. The mortality rate was significantly higher in those patients with postoperative pancreatitis. Acute pancreatitis in the elderly carries a grave prognosis. All patients should undergo thorough evaluation, as biliary tract disease is the most common cause. Cholecystectomy should be performed in those with biliary disease to prevent recurrent attacks.

Endoscopic retrograde cholangiopancreatography in the management of pancreatic pseudocysts.

The value of ERCP was studied in 25 patients with pancreatic pseudocysts. There were no episodes of sepsis; however, acute pancreatitis developed in one patient for an overall complication rate of 4 percent. Results of ERCP were positive in 24 of the 25 patients (96 percent), with filling of the pseudocyst in 17 and pancreatic ductal obstruction in 7. Biliary tract abnormalities were found in seven patients and included common bile duct strictures in four, bile duct dilatation in two, and cystic duct obstruction in one. ERCP also detected six pseudocysts not diagnosed by ultrasonography, five of which were small and resolved with nonoperative therapy. ERCP is a safe diagnostic procedure for patients with pancreatic pseudocysts and may provide important information about coexistent biliary tract disease not otherwise available. It is also sufficiently sensitive to detect small pseudocysts that otherwise would be missed.

Evaluation of ischemic intestine by Doppler ultrasound.

Intraoperative Doppler ultrasound examination of ischemic intestine was used to determine viability and to establish margins of resection, even when the findings differed from the surgeon's clinical appraisal. Ten of 25 segments in 23 patients were clinically judged nonviable, but because of arterial flow within the segments was detected by Doppler ultrasound, none was resected. The subsequent benign clinical courses of the patients demonstrated the viability of the segments. Two segments were judged clinically viable, but because Doppler signals were absent, both were resected. Histologic examination demonstrated severe ischemic changes in both segments. Nine segments were judged both by clinical criteria and by Doppler ultrasound examination to be nonviable, and all nine were resected. Histologic examination confirmed ischemia or infarction in all. Doppler ultrasound was a more reliable intraoperative predictor of viability of ischemic intestine than clinical assessment alone, and its use averted postoperative complications and unnecessary second-look procedures.

Cholecystectomy in elderly patients.

Cholecystectomy was performed in 93 patients over the age of 70 years with an overall mortality of 7.5 percent. Complications occurred in 28 percent. Patients who underwent elective operations fared far better than those who required emergency surgery. Of the 50 patients who underwent elective cholecystectomy, there was 1 death (2 percent), and 10 patients (20 percent) experienced complications. In contrast, of the 43 patients who required emergency operation, 6 died (14 percent). Complications occurred in 14 (33 percent). Elective cholecystectomy in the elderly patient with symptomatic biliary tract disease is advocated before acute complications that necessitate emergency operation develop.

Use of Doppler ultrasound in intestinal surgery.

Doppler ultrasonography was used intraoperatively in 117 patients undergoing intestinal anastomosis or enterostomy to determine the adequacy of blood supply at the margins of resection. Doppler findings were compared with clinical assessment of intestinal blood flow by the operating surgeon. In 92 per cent of cases, Doppler signals and clinical observation coincided. However, in five of six cases in which Doppler signals were absent at one margin, the surgeon resected additional intestine, selecting margins within 1 cm of the nearest arterial Doppler signal. All five patients had uneventful healing. In the one case in which the surgeon chose to rely onthe appearance of the bowel despite the absence of Doppler arterial signals, ischemic necrosis of the proximal segment and anastomotic disruption occurred. The technique of Doppler ultrasonography is readily learned, and the instrument is available in most hospitals. Intraoperative use of Doppler ultrasonography can help identify intestine lacking a blood supply adequate to assure viability before changes in the appearance of the bowel alert the surgeon to the problem.

EEA esophageal stapling for control of bleeding esophageal varices.

Esophageal transection with the EEA stapler was performed in five patients with bleeding esophageal varices. Bleeding from varices has not recurred in surviving patients during follow-up of up to 27 months. One death occurred during the postoperative period. Esophageal transection with the EEA stapler is an effective means of preventing recurrent variceal hemorrhage. This technique is best suited for patients requiring emergency operation to prevent exsanguination and for those in whom a major shunting procedure is contraindicated because of the severity of hepatic disease or other medical illness.

Spontaneous aortocaval fistula with paradoxical pulmonary embolization.

The present report discusses the clinical syndrome and the management of a patient with an aortocaval fistula secondary to an abdominal aortic aneurysm. The occurrence of paradoxical pulmonary embolization with this syndrome is reported.