Splenic reimplantation does not affect outcome in chronic canine model.

The effects of septic insult were compared in a canine model of splenic reimplantation. Sequential changes in hematologic, hepatic, and immunologic function were monitored biweekly in 18 dogs during 10 months after splenectomy, splenectomy with reimplantation, or sham operation. There was no significant difference in these measures between the two groups. At the end of the 10-month period, spleen scans with technetium (99Tc) labeled, heat-damaged RBCs were obtained on the reimplanted dogs. 99Tc scanning revealed no active splenic implants at 10 months. All dogs were then infected with intravenous Type III pneumococcus for 9 consecutive days. There were no measurable hematologic, hepatic, or immunologic differences between groups before or after the septic insult. These animals were then sacrificed for histologic analysis of the splenic reimplants. Reimplant histology showed active germinal centers, but the surrounding pulp was fibrotic and lymphocyte-depleted. Splenic reimplantation in this canine model yields no apparent benefit.

Recurrent spontaneous intrahepatic hemorrhage from peliosis hepatis.

Peliosis hepatis is a rare and highly lethal liver lesion in which numerous blood-filled cavities or cystic spaces are dispersed throughout the hepatic parenchyma. The cause is unknown, although the condition is associated with several disease states and medications. Patients may present with hemorrhage, liver failure, the hepatorenal syndrome, cholestasis, or portal hypertension. We treated a patient who survived two separate hemorrhages from peliosis hepatis. The surgical intervention used, hepatic dearterialization, has allowed this patient to remain asymptomatic for 5 years.

The fate of 100 prolonged venous access devices.

The fate of 100 prolonged venous access devices (PVAD) placed for chemotherapy (97) or antibiotics (3) during a three-month period was prospectively evaluated. The PVAD included 52 double lumen Hickman (DLH), 29 Infuse-a-port (IAP), and 19 single lumen Hickman (SLH) catheters using percutaneous puncture in 72 pts and venous cutdown in 28 patients. The Hickman catheter subcutaneous tunnel ranged from 4-20 cm with the cuff placed 0.5 to 10 cm from the exit site. Each patient was contacted at two-week intervals to determine the state of the catheter until removal or death. After a one-year follow-up period, 16 per cent of the PVAD remain in place. There were 37 deaths and 22 PVAD were removed after completion of treatment. Mechanical problems led to removal in 12 patients including venous thrombosis (4), poor placement (3), occlusion (3), and a leaking device (2). There were four catheters that "fell out" and nine (8 DLH, 1 SLH) were removed for infection; all 13 catheters were placed in a subcutaneous tunnel less than or equal to 6 cm with the cuff 0.5 cm from the exit site. This study is unique in its accurate determination of fate; 40 per cent of the patients would have been "lost to follow-up" had a retrospective chart review been used, as many patients died at home or had their PVAD removed elsewhere. Recommendations to increase catheter life/patient satisfaction include 1) IAP as the PVAD of choice, 2) SLH preferable to DLH and 3) placement of long Hickman catheter tunnels (greater than or equal to 10 cm) with cuff greater than or equal to 2 cm from exit site.

Oxygen saturation monitoring during endoscopy.

The role of monitoring during endoscopy is not clearly defined. We have prospectively investigated continuous arterial oxygen saturation (SaO2) monitoring in 326 patients undergoing upper endoscopy (EGD) and 90 undergoing colonoscopy. Automated blood pressure recording was evaluated in 278 of these patients. SaO2 desaturation (less than 90%) occurred in 17.8% of patients undergoing EGD and 12.9% undergoing colonoscopy. Systolic blood pressure abnormalities (greater than 200 or less than 90 mmHg) occurred in 19.8% of EGD patients and 19.6% of colonoscopy patients. Treatment based on these abnormalities was required in 4.3% of patients during EGD and 8.8% during colonoscopy. A history of pulmonary or cardiac disease predicted increased risk during colonoscopy, while cardiac disease and age 60 years or above predicted desaturation during EGD. Pulse oximetry and automated blood pressure monitoring was especially valuable during endoscopy in the elderly and patients with cardiac or pulmonary disease. It may be used as a guide to therapeutic intervention and to avert major cardiopulmonary complications.

Emergent endoscopic retrograde cholangiopancreatography. A highly specific test for acute pancreatic trauma.

Emergent endoscopic retrograde cholangiopancreatography (ERCP) was assessed as the definitive diagnostic test for acute pancreatic injury in a 23-year-old male automobile driver who sustained blunt abdominal trauma. Despite the patient's quiet, tender abdomen, rising serum amylase level, and an abdominal computed tomographic scan demonstrating probable pancreatic transection, a nonoperative approach was successful when an emergency ERCP demonstrated normal ductal anatomy. This approach is advocated when the presence of a possible pancreatic injury is the only reason for a planned exploratory laparotomy.

Changes in oxygenation and pulse rate during endoscopy.

Continuous monitoring of arterial oxygen saturation and heart rate with a pulse oximeter was performed in 100 consecutive patients undergoing esophagogastroduodenoscopy (78) or colonoscopy (22). Twenty-four patients had decreases in their estimated arterial PO2 level to less than 60 mm Hg during or just after the procedure. In 15 patients the hypoxemia was transient, but in nine others, treatment was required. Twenty patients also developed a tachycardia greater than 120 beats/minute.