Improved graft patency associated with altered platelet function induced by marine fatty acids in dogs.

Female mongrel dogs fed a marine fish diet rich in long-chain polyenoic fatty acids had improved patency of small-diameter arterial prosthetic grafts as compared to controls. Also, in vivo platelet function as measured by bleeding times was significantly prolonged. Eicosapentaenoic acid, not found in the serum of control animals, was present in relatively high concentrations in both the serum and a platelet-rich fraction of the marine oil-fed group. Eicosapentaenoic acid, unlike arachidonic acid, does not induce platelet aggregation and this phenomonon may account for the altered platelet function demonstrated in our animals and hence the improved graft patency. These data lend further support to the role of platelets in determining the patency of vascular grafts.

Primary malignant retroperitoneal tumors. Current management.

Our experience with 16 retroperitoneal tumors seen over a 13 year period has been reported. Patients presented with either an abdominal mass or abdominal pain associated with a large retroperitoneal tumor. Delineation of the tumor is best accomplished with computerized tomography and venacavography. Exploration and resection is possible in most patients. Postoperative radiotherapy and chemotherapy are recommended in most patients. Local recurrence frequently occurs and should be diagnosed early and resected aggressively if found.

Abdominal aneurysmectomy following previous peritonitis.

Repair of abdominal aortic aneurysms in two patients (one emergency and one elective) several months after a bout of peritonitis resulted in graft sepsis. Bacteria cultured from the episodes of peritonitis and from graft sepsis were identical. Repair in elective cases should probably be postponed for at least one year. In urgent or emergency cases, especially when any contamination is encountered, ligation of the aorta and extra-anatomic bypass grafts should be performed.

The complicated septic abdominal wound.

Since 1975, we have treated 21 patients with severe postoperative liquefaction fascial necrosis of the abdominal wall (group A, 13 patients), postoperative fascial necrosis with an associated intestinal fistula(e) within the wound (group B, three patients) and postoperative fascial necrosis with multiple internal bowel fistulae causing continuing peritoneal contamination (group C, five patients). Management in group A included general exploratory laparatomy, drainage of intra-abdominal abscesses, debridement of necrotic fascia, and loose closure of the wound with polyethylene (Marlex) mesh. Treatment in group B consisted of suture closure of exposed bowel fistulae with skin flap coverage. Group C was treated with diverting jejunostomy and suture closure of distal fistulae to avoid hazardous dissection and preserve bowel length. Overall survival was 71%.

Arterial embolectomy in the leg. Results in a referral hospital.

The clinical characteristics and course of 90 patients in whom 121 arterial emboli occurred from 1968 to 1978 were reviewed. The factor that correlated most significantly with a favorable outcome was the interval from onset of symptoms until arterial embolectomy was performed. The results of embolectomy were excellent in the patients operated on within 6 hours of symptoms (amputation rate 4 percent, mortality rate 15 percent), but less favorable in the patients operated on within 6 to 12 hours of onset of symptoms (amputation rate 27 percent, mortality 40 percent). Mortality (48 percent) and amputation (52 percent) rates in the patients operated on 12 to 48 hours after onset of symptoms were excessive. It is recommended that immediate embolectomy be performed in all potentially viable extremities in patients who present within 12 hours of symptoms, but that after 12 hours only those limbs with obvious viability (not paralyzed or anesthetic) should be operated on. Alternatives for the remainder are high dose intravenous heparinization or expedient amputation. In patients who present greater than 60 hours after the onset of symptoms, embolectomy can be performed with low morbidity and mortality.

Emergency arteriography in extremity trauma: assessment of indications.

Two hundred and four cases of extremity trauma were evaluated. Arteriography was performed in 70 patients for one or a combination of the following indications: absent or diminished pulse, proximity to a major vessel, enlarging or significant hematoma, neurologic deficit, fracture or dislocation, or systemic hypotension. Of the 70 patients, 37 (53%) demonstrated positive arteriographic findings; the most common was arterial occlusion. Patients with an absent or diminished pulse, the most reliable indicator of arterial injury, should have immediate arteriography. Patients who have strong and equal peripheral pulses and are clinically stable should be observed and undergo elective arteriography. Three patients with intimal injuries had intact pulses, but no pattern of indications was helpful in identifying these injuries. A combination of indications is indicative of more serious injury and more likely to produce a positive arteriographic study.

Spontaneous diabetes mellitus in the New Zealand white rabbit: preliminary morphologic characterization.

Electron microscopic studies on a closed colony of rabbits with an 18.5 per cent incidence of spontaneous onset insulin-dependent diabetes mellitus revealed that the beta-cells of the islets of Langerhans of the diabetic animals were hypergranulated. This finding contrasts with most other animal models of spontaneous diabetes mellitus which show degranulation of the beta-cells. There was no evidence of hyperplasia, insulitis, amyloid, or fibrosis of the islets by either light or electron microscopy. Correlation of our morphologic findings with physiologic data suggests a defect in insulin secretion. Rabbits with normal glucose metabolism showed a normal degree of granulation of their beta-cells. The alpha and delta cells were within normal limits in all animals. No other abnormalities associated with diabetes in humans or other animals were noted except for minimal fusion of the glomerular epithelial foot processes and mineralization of the proximal tubules and Bowman's capsules.

Infected prosthetic grafts.

An experience with 20 infected prosthetic grafts in a series of 652 prosthetic arterial reconstructions has been reviewed. There was 13 aortofemoral, one straight aortic, three femoropopliteal, one carotid subclavian, one axilloaxillary, and an axillocarotid graft. The most common site of infection was the groin. All patients had received preoperative and postoperative broad-spectrum antibiotic coverage, perhaps contributing to a high incidence of Gram-negative bacterial cultures. Early procrastination contributed to morbidity and mortality. Attempts at local wound management with drainage and irrigation generally failed, especially if the suture line was involved. Graft excision without revascularization resulted in a number of amputations and a high mortality. Excision of the entire aortofemoral graft combined with extra-anatomical revascularization was uniformly fatal. Our experience suggests that the first objective should be to establish operatively the extent of the infection. If very localized, antibiotic irrigation may cure. Involvement of one side can be treated in one stage by extra-anatomical bypass using the obturator foramen coupled with excision of the infected portion. If the entire graft is involved, we recommend extra-anatomical bypass as the initial procedure. High-dose antibiotic for systemic effect are then administered and two to three days later the infected graft is removed.

Acute perforations of the sigmoid colon secondary to diverticulitis.

Diverticulitis is a complex disease and demands careful cooperation between physician and surgeons, because although it is a benign disease, the presence of complications makes it potentially lethal. For successful management, knowledge of the treatment in past decades should be integrated with current surgical technics. A retrospective review of forty-one patients with perforated diverticulitis revealed a significant decrease in morbidity and hospital stay for the group of patients undergoing the Hartmann procedure versus the group undergoing the classic three stage approach. In addition, the Hartmann group required fewer additional surgical procedures for drainage of abscesses. In view of these results as well as those of others, we believe that resection is the primary goal of therapy. The two stage approach therefore offers significant decrease in morbidity with acceptable mortality.

Bilateral angiomyolipomas and renal cell carcinoma in polycystic kidney.

A case is presented of a twenty-eight-year-old man in whom renal failure developed at age twenty-four from polycystic kidney disease known to be present since childhood. He also had cutaneous manifestations of the tuberous sclerosis complex. Intrarenal hemorrhage led to bilateral nephrectomy. Microscopic examination disclosed typical polycystic disease and multiple angiomyolipomas in each kidney. In addition several renal cell carcinomas of oncocytic, papillary, and clear cell type were found. Review of the literature disclosed the uncommon coexistence of any two of these lesions and did not uncover any reported case of the simultaneous existence of all three.

Renal transplantation in a patient with lipoatrophic diabetes. A case report.

A patient with congenital generalized lipodystrophy developed nephrotic syndrome with progressive renal glomerulosclerosis attributed to diabetic nephropathy. Renal transplantation was performed and the patient was discharged with normal renal function. Marked hyperlipidemia (17,500 mg/dl) persisted. One month later renal malfunction developed, and an open renal biopsy was performed when there was no response to antirejection therapy. Massive lipid deposition in renal tubular cells with tubular necrosis and hemorrhage was present but only minimal evidence of graft rejection. Rejection therapy was tapered and renal function stabilized. Death occurred 2 months later because of pulmonary sepsis. Patients with generalized lipodystrophy and severe hyperlipidemia may be at an unusually high risk for renal homograft destruction.

Chylous ascites complicating retroperitoneal lymphadenectomy for testis tumors: management with peritoneovenous shunting.

Two cases of chylous ascites secondary to lymph node dissection for testicular tumors are reported. Non-surgical management failed to control the ascites in either patient. The use of the LeVeen shunt promptly and permanently controlled the ascites in 1 patient.