Ocular fluorophotometry in streptozotocin diabetes mellitus in the rat: effect of pancreatic islet isografts.

Fluorophotometry was used to evaluate the integrity of the blood-ocular barriers to fluorescein in experimental diabetes mellitus in rats. This technique allowed quantitation of ocular fluorescein concentrations following intravenous injection. Streptozotacin-induced diabetes resulted in an increased fluorescein accumulation in the anterior chamber (1.52 +/- 0.17 microgram/ml, mean +/- S.E.M.) and vitreous (0.82 +/- 0.11) over baseline nondiabetic levels (0.68 +/- 0.80 and 0.40 +/- 0.03, respectively). Fluorophotometry was repeated at 5, 13, and 20 days following portal vein pancreatic islet transplantation. At 5 days anterior chamber (1.40 +/- 0.17) and vitreous (0.61 +/- 0.08) fluorescein concentrations remained elevated. However, at 13 and 20 days following islet transplantation, ocular fluorescein concentrations were identical to levels observed prior to the induction of diabetes. Intravenous glucose (0.5 gm/kg) tolerance testing was performed 5 and 13 days following transplantation. The glucose responses to the tolerance test were normal and similar at both times. However, at 5 days the insulin response was abnormal with a decreased initial peak and an absent second peak. At 13 days there was a normal biphasic insulin response. In experimental diabetes mellitus ocular vascular permeability was more closely correlated with insulin than blood glucose abnormalities.

A pilot program of multiple cadaver organ and tissue retrieval.

A one year pilot project conducted at a 2,000 bed medical center involved a unique approach to the retrieval from cadavers of multiple viable organs and tissues. Aspects of the program included a special unit for sterile evaluation and storage of tissue, a computerized registry of potential donors, a nurse to coordinate and expedite retrieval, and a retrospective chart review to define the incidence and location of potential cadaver donors. There were requests for 121 tissues by 39 investigators. Eleven different tissues were needed within 4 hours of death. Forty-two percent of individuals contacted directly enlisted in the donor registry, three of whom were identified on the computer at the time of death. A five-fold increase in cadaver donor evaluation referrals occurred, and one third of referrals resulted in viable tissue retrieval. A review of 728 deaths indicated that 45% could have been potential eye donors, 27% pancreas donors and 2.5% kidney donors. A coordinated program to retrieve multiple viable organs and tissues for transplantation and research appeared to be effective in this initial pilot study.

Reanastomosis after jejunoileal bypass.

One hundred and one patients underwent jejunoileal bypass after careful preoperative evaluation. These patients were re-evaluated after operation on a frequent basis, and 23% have required restoration of intestinal continuity (reanastomosis) by a mean postoperative time of 44 months. The most frequent reasons for reanastomosis were liver dysfunction (5% of the entire series), severe malnutrition or weakness (5%), and late electrolyte imbalance (4%). Two patients did not survive reanastomosis, both having liver failure. Of the patients who did survive, weight gain (approaching prebypass weight) and improvement in liver function tests, electrolyte balance, serum vitamin levels, and diarrhea have been the rule. Of the entire series of 101 patients who underwent bypass, 58% either had life-threatening complications, had to be reanastomosed, or died. These morbidity and mortality rates raise the important question of whether jejunoileal bypass is an appropriate procedure for the treatment of morbid obesity.

Computer-assisted instruction in surgery.

Computer-assisted instruction (CAI) is an educational medium which provides a highly interactive, adaptive, and individualized learning experience for the student or physician. A CAI system has benn developed to prepare a curriculum in general surgery. The surgical seminars written on this system have been used enthusiastically by students, residents, and interns for the past 18 months. Using a computer terminal (printer or television screen) connected by telephone to a minicomputer, the user participates in simulated seminars with the authors, viewing information and answering questions based on the material presented. The student responds by typing the answer in his own words, and the computer (author) responds with further information designed specifically for that answer. This response may support or contest what the student said, may branch the student to material covered previously, or instead may lead the student through as much remedial material as he needs. A more sophisticated student will progress rapidly through the seminar. Twenty-five surgeon/authors (at 15 medical schools) are preparing seminars, and it is planned that a complete library in general surgery will be available to departments of surgery nationally by September, 1978, via the Health Education Network.

Jejunoileal bypass for morbid obesity. A critical appraisal.

One hundred one carefully screened morbidity obese patients underwent jejunoileal bypass and were followed closely over a mean follow-up period of 32 months. Although there were no operative deaths, three per cent of patients died postoperatively of liver failure or its complications. A fourth patient died of a pulmonary embolus after reoperation, and the fifth patient died cachectic with severe diarrhea after excessive weight loss. Nineteen per cent of the patients required restoration of intestinal continuity (reversal), most for either liver failure or late fluid and electrolyte derangements. All but two survived reversal and are doing well despite massive weight gain. Fifty-eight per cent of the patients had major complications which either required major reoperation (reversal, cholecystectomy or incisional hernia repair) or were potentially life-threatening (liver failure, hepatic fibrosis or urinary tract stones). As described in other series, abnormalities in serum electrolytes and vitamins were seen. In addition, hypovitaminosis D occurred in a number of patients and as with other serum parameters measured, was time-dependent in that improvement was seen in most patients over the postoperative interval studied. Because of the high rate of complications and reversals, we believe that jejunoileal bypass should be reserved for patients with morbid obesity whose lives are imminently threatened by obesity or its sequellae.

Gastric complications after radiotherapy for Hodgkin's disease and other lymphomas.

Six patients who originally received radiotherapy for Hodgkin's disease or primary gastric lymphoma developed radiation injury of the stomach requiring surgical management. Only two of these patients had evidence of gastric neoplastic involvement at the time of treatment. Experience with these patients leads us to draw the following conclusions: (1) Symptoms of radiation injury mimic those of recurrent neoplastic disease. (2) The effects of radiation are progressive and may be resistant to medical management. (3) The indications for surgical management include perforation, hemorrhage, obstruction, intractable pain, fistula formation, and inability to rule out recurrence. (4) Parenteral hyperalimentation can be an important adjunct in preparing debilitated patients for operation. (5) Gastric resection with gastrojejunostomy is the preferred operation. (6) Frozen section examination can be useful in determining the proper level of resection.