Abdominoperineal resection in the treatment of devascularizing rectal injuries.

Local debridement, drainage, and diverting colostomy, with or without primary repair of the rectum, have been considered to be the standard treatment for most rectal injuries, but they are not sufficient for those patients sustaining uncontrollable bleeding or extensive rectal devascularization. This report assessed the indications and results of abdominoperineal resection of the rectum in these patients. Ten patients who were victims of explosive trauma presented with massive perineal injuries and extensive rectal devascularization. Six of these were treated with local debridement of necrotic tissue, pararectal drainage, antibiotics, and colostomy. Five of the six patients initially treated by colostomy died after operation from hemorrhage or sepsis. The sixth patients, who survived, had an abdominal resection of the rectum performed 5 days after the colostomy for removal of a gangrenous rectum. All five of those who underwent abdominoperineal resection survived (p less than 0.01). Increasing violence in the life patterns of modern society enhances the possibility of occurrence of this type of lesion, previously limited to military practice. The need for careful investigation of rectal viability is emphasized. Primary abdominoperineal resection of the rectum is advised when extensive devascularization has occurred.

Radioisotope detection of venous thrombosis. Venous scan vs fibrinogen uptake test.

Experience with the fibrinogen uptake test and the technetium Tc 99m albumin aggregated venous scan in 89 patients showed the latter to be adequate for simultaneous screening for plumonary embolism and venous thrombosis of the lower extremities and pelvis. Because the fibrinogen uptake test differentiated active from inactive venous thrombosis, it is indicated when anticoagulation is considered for patients with a history of thrombophlebitis and equivocal clinical findings of acute activity. It can also be used to monitor high-risk patients and to detect proximal propagation of thrombi. The results of the technetium venous scan were abnormal in 97% of patients with venous thrombosis and the fibrinogen uptake test detected 100% of patients with acute activity. Both tests react to different aspects of the thrombotic disease, thus complementing each other. Because of their reliability, indications for phlebography are now less frequent.

Noninvasive cerebrovascular evaluation: a prerequisite for angiography?

Results of cerebrovascular evaluation were reassessed in 768 patients to determine whether angiography performed in unselected patients was safe and economically efficient, and whether previous noninvasive screening was sensitive enough and effective in increasing the yield of subsequent angiography. In 543 patients undergoing angiography without previous noninvasive screening, positive results were obtained in 21 percent. Complications included hemorrhage (2.4 percent), neurologic deficit (2.2 percent), and death (0.2 percent). Of 225 patients undergoing previous screening with Doppler, ophthalmoplethysmography, and carotid phonoangiography, none with negative screening results had subsequent cerebrovascular complications. Of 82 patients having positive noninvasive test results, 53 underwent angiography with a 74 percent yield of positive results. Twenty-nine had no angiography or corrective therapeutic action. Of these, 3 percent died after a cerebrovascular accident, and 21 percent developed complete stroke (mean follow-up 3 years). Noninvasive screening reliably eliminated necessity for angiography in 64 percent of patients while increasing the angiographic yield from 21 to 74 percent. Therefore, performance of cervicoencephalic angiography is asymptomatic and unselected patients cannot be condoned any longer. Likewise, positive noninvasive screening results should not be ignored because in the absence of treatment, death (3 percent) and permanent neurologic deficit (21 percent) occur over a 3 year period.

Inflammatory carcinoma of the breast. A therapeutic approach followed by improved survival.

Disappointing results of radical mastectomy for treatment of inflammatory breast carcinoma led to its abandonment and the use of alternative therapeutic methods without improvement of survival rates. Results of radical mastectomy combined with other therapeutic modalities have not been fully evaluated so far. In a series of nine patients with proven inflammatory breast carcinoma and no distant metastases, two underwent radiotherapy, oophorectomy, and adrenalectomy (group A) and seven underwent preoperative irradiation, radical mastectomy, postoperative irradiation, and chemotherapy (group B). There were no local recurrences in either group. Group A patients survived five and eight months (mean, 6.6+/-2.1) and patients of group B survived 45.5+/-26.2 months (p less than 0.05). Results show no rational basis for withholding radical mastectomy, but suggest that improved survival may be obtained when radical mastectomy is an integral part of a rational sequential therapeutic schedule.

Short-term femoral vein catheterization. A safe alternative venous access?

Results of femoral vein catheterization were compared with those of subclavian and antecubital vein catheterization in 2,345 combat casualties during treatment of hypovolemic shock. Femoral vein catheterization was successful in 95.5 per cent of cases. Accidental arterial puncture occurred in 6.3 per cent, hematomas in 1.3 per cent, and infection in 1.4 per cent. Subclavian vein catheterization was successful in 92.4 per cent. Arterial puncture occurred in 0.4 per cent, hematomas in 0.3 per cent, infection in 1.1 per cent, pneumothorax in 1.4 per cent, and hydrothorax in 0.4 per cent. Antecubital vein catheterization was successful in 77.6 per cent, infection developed in 3.3 per cent, and phlebitis occurred in 5.6 per cent. No clinically detectable phlebitis occurred after either femoral or subclavian vein catheterization. The low morbidity of femoral vein catheterization in this series suggests that this approach be considered when short-term massive intravenous fluid administration is indicated in the treatment of circulatory collapse or cardiac arrest.

Pancreatic pseudocyst: management in fifty-four patients.

The management of pancreatic pseudocyst was reassessed in fifty-four patients: only sixteen (30 per cent) regressed with nonoperative management; six (11 per cent) died of septic complications; and thirty-two (64 per cent) eventually required operation. Most pseudocysts did not regress with nonoperative therapy, thus emphasizing the need of serial clinical and ultrasonic examination at frequent intervals to detect nonresolution or complications requiring earlier operation than previously advocated.

Detection of anticoagulation therapy failures in patients with venous thrombosis.

Results of ultrasonic monitoring of venous patency and fibrinogen uptake testing were evaluated in ten patients with venous thrombosis receiving heparin therapy. Two propagating venous thromboses were detected 24 to 48 hours before massive pulmonary embolism developed, thus emphasizing the usefulness of these methods for detection of anticoagulation therapy failures.

Adult respiratory distress syndrome in postoperative patients: study of pulmonary pathology in "shock lung" with prophylactic and therapeutic implications.

Lungs of 44 patients who died after postoperative respiratory distress and shock had a significantly higher incidence of atelectasis and thromboembolism than did 31 control patients. However, both lesions were as inconstant in occurrence as all other 15 investigated pulmonary changes. Moreover, no clear correlation between lung pathology and duration of shock was found and the incidence of thromboembolism was too low (one clot for each 16 or more counted vessels) to generate any significant vascular obstruction. Furthermore, pulmonary pathology in patients with postoperative respiratory distress was independent of the presence or absence of shock and some of the most typical findings of "shock lung" were more often present in patients who did not have shock but died of aspiration pneumonia. While possibly a contributing factor, shock is not the most important cause of the pulmonary lesions in postoperative patients. The term "shock lung" should be eliminated and renewed emphasis should be placed on detection, prevention and treatment of the pathogenic mechanisms involved in each individual case.

The rigid versus soft postoperative dressing controversy: a controlled study in vascular below-knee amputees.

Results of 52 consecutive below-knee amputations for lower extremity ischemia were evaluated to determine whether use of immediate fit prostheses (IPOP) instead of soft stump dressings had any bearing postoperative hospitalization time, functional recovery, postoperative pain, morbidity, and mortality in amputees. Of 34 patients receiving IPOP, 21 per cent developed stump necrosis, 21 per cent had wound infection, 26 per cent required major reamputation, and 12 per cent died within 30 days of operation. Of 18 patients treated with soft stump dressings, 17 per cent developed necrosis, 33 per cent infection, 44 per cent required reamputation, and 11 per cent died postoperatively. None of these differences was statistically significant. Mean hospitalization time and average narcotic requirements for analgesia were also similar in both groups. Fifty-six per cent of patients with IPOP and 22 per cent of those with soft dressings ultimately ambulated with prostheses (P less than 0.05). Whether or not IPOP was used had little if any effect on the early evolution of vascular amputees in this series.

Massive spontaneous hemoperitoneum due to rupture of visceral branches of the abdominal aorta.

Review of 153 cases of massive spontaneous hemoperitoneum following visceral arterial rupture showed that 94% of all young women and 100% of all pregnant women had ruptured congenital splenic artery aneurysms at the time of hemorrhage, whereas young males bled from a variety of sources. Individuals who were 45 years old or older bled either from lesions of the celiac axis or its branches (66%) or from arterial mesenteric system lesions (34%). Only 22% of the older individuals of either sex bled from splenic artery sources. Arterial hypertension was present in 40% and previous or simultaneous intracranial hemorrhage occurred in 9% of the older patients. There were no survivors among those in whom the bleeding source was not operatively controlled. With operation, 79% of the younger patients and 57% of the older ones survived. Results emphasize the high mortality of visceral artery rupture with intraperitoneal bleeding. Prophylactic excision is advised for all complicated aneurysms regardless of age and all uncomplicated aneurysms in healthy individuals, especially in fertile or pregnent women.

Fibrinogen uptake test. Criteria for interpretation of results in patients with venous thrombosis.

Accurate detection of active deep venous thrombosis with the fibrinogen uptake test (FUT) requires adherence to rigid criteria for interpretation of results of the tests. In a series of 56 patients, only detection of serial increase of per cent uptake at the same position correlated with presence of active venous thrombosis in all cases. Other investigated criteria, which were based on the analysis of single FUT results, showed a 21% incidence of false positive results. Accordingly, active venous thrombosis investigation by FUT requires performance of serial tests and analysis of the curve of uptake at each position to detect serial increasing per cent uptake.

Arterial scan versus radiographic angiography in detection of shallow arterial ulcers.

A comparison of 99m-technetium albumin aggregated arterial scan and radiographic angiography for detection of shallow intimal carotid artery ulcerations was made in a series of 12 anesthetized dogs, having a total of 16 acute arterial ulcerations. Radiographic angiography showed positive findings related to presence of stenosis or mural thrombosis in 12 instances. Direct visualization of ulceration was only exceptionally encountered. Arterial scan detected 14 of 16 intimal ulcers. The radionuclide method was reliable even in absence of stenosis or when only minimal mural thrombosis was present. Moreover, autopsy scan of the isolated arterial segments detected all 16 intimal lesions. These results indicate that the arterial scan was a more reliable method for detection of shallow arterial ulcers in this experimental model than radiographic angiography, especially when arterial lumen stenosis or mural thrombosis were minimal or absent.

Sodium nitroprusside pharmacoangiography: arteriographic enhancement by local vasodilation.

Sodium nitroprusside (SNP) was injected intra-arterially into the right femoral artery of five dogs, to promote arteriographic enhancement with minimal systemic effects. Injection of 3 microgram/Kg SNP or more, produced tachycardia, hypotension and increased pulsatile arterial blood flow. a 36% pulsatile arterial flow increase, which lasted 25 seconds or less, was the most remarkable systemic change seen after intra-arterial injection of 2.5 microgram/Kg SNP. Small doses were followed by even lesser systemic changes but were ineffective in promoting arteriographic enhancement. Comparison of arteriograms obtained before and after 2.5 microgram/Kg SNP injection showed increased arterial diameter, greater architectural detail and extensive visualization of previously undetected smaller arteries in post-SNP angiograms. Thus, suggesting that 2.5 microgram/Kg was the optimal SNP dose for production of local arterial without remarkable systemic effects. Good results of SNP pharmacoangiography in this experimental series suggest that further research on this topic is warranted.

Early diagnosis of anticoagulation failure: can recurrent pulmonary embolism be prevented?

Propagating thrombosis, occurring in spite of full anticoagulation, is an early indication of the failure of anticoagulation therapy. Its detection can be successfully accomplished by routinely monitoring all heparinized patients with serial fibrinogen uptake tests or serial Doppler ultrasound venous flow evaluation in selected lower extremity veins. If anticoagulation therapy failure is detected, it should be corrected immediately. In already fully anticoagulated patients who nevertheless develop propagating thrombosis, inferior vena cava interruption should be performed before potentially lethal pulmonary embolism occurs.