Initial experience wit polytetrafluoroethylene for extraanatomic bypass.

Extraanatomic bypass using polytetrafluoroethylene is a satisfactory alternative to direct aortic surgery in poor risk patients and in patients who have had previous aortoiliac reconstruction. If the disease is limited to one side, a crossover graft gives very satisfactory results with a 1 year cumulative patency of 95.6 percent. Axillofemoral grafts also give satisfactory results, especially if episodes of thrombosis are treated promptly by thrombectomy, in which case flow will be restored in most cases, with an overall 1 year cumulative patency of 89.5 percent.

Rubber sump drainage of enterocutaneous fistulae.

Effective sump drainage of high enterocutaneous fistulae, together with alimentary rest and total parenteral nutrition, is now an integral part of the modern management of patients with this condition. The low tissue reactivity of the plastic and polymer materials currently used in most drainage tubes appears however, to be counterproductive to the establishment of a discrete fistula track and control of the fistula. A case is made for the use of red rubber sump drains for enterocutaneous fistulae. The greater tissue reactivity of rubber is reviewed and confirmed by animal experimentation. A method of rubber sump drainage of enterocutaneous fistulae developed during the management of 83 such fistulae is described.

Continuing peritoneal lavage in high-risk peritonitis.

A total of 27 patients with peritonitis who were considered to have poor prognoses were treated with a continuing peritoneal lavage of 1.5% Dianeal containing gentamicin sulfate, cephalothin sodium, and lincomycin. Twenty-one patients survived (78%), and only two patients developed intraperitoneal abscesses. The major benefit was found in those patients with gross peritoneal contamination. Anastomotic integrity was not affected by the lavage.

Arterial reconstruction with polytetrafluoroethylene: a preliminary report.

Early results of arterial reconstruction with reinforced expanded polytetrafluoroethylene (PTFE) in the lower extremity have been obtained by reviewing 55 patients undergoing 59 operations - 38 femoropopliteal bypasses and 21 long bypasses distal to the popliteal artery. The one-year accumulated patency rates were 73% for the femoropopliteal bypass group and 50% for the long bypass group. Early results suggest that PTFE is superior to Dacron and is an acceptable substitute for autogenous saphenous vein when the latter is unavailable or of inadequate calibre.

Generalized infective peritonitis.

A mortality of almost 50 per cent from generalized infective peritonitis was obtained. Diagnosis was made chiefly on clinical grounds. Delay was common. Investigations were primarily useful in determining the degree of metabolic derangement. A worsened prognosis could be predicted by several factors assessed preoperatively. The usual cause of death was continuing intraperitoneal sepsis. This was manifest as multisystem failure in an intensive care environment. Abdominal signs of this infection were infrequent.

Pathogenesis of congenital malformations. An hypothesis.

An hypothesis of neural crest injury, derived from a radiologic analysis of thalidomide deformities, is suggested as a possible pathogenetic mechanism of dysmelia and its associated visceral defects. Supportive evidence from a variety of sources is presented, and the hypothesis is shown to provide a unifying concept for a number of previously unrelated facts.

Leiomyosarcoma of the duodenum: a report of three cases.

Three cases of leiomyosarcoma of the duodenum are reported in this paper. The first patient demonstrated the development of a leiomyosarcoma from a leiomyoma, and also posed diagnostic problems as a Pólya gastrectomy had previously been performed. The second patient presented with acute pancreatitis--a hitherto unreported complication of this condition. The third patient showed that even though the primary tumour was unresectable, the patient remained well for more than a year after diagnosis.

Distal lower limb arterial reconstruction with modified allograft saphenous veins.

Cadaveric donor saphenous veins subjected to proteolytic enzymatic digestion, crossbonding and heparin bonding were used for arterial reconstruction in the legs of 13 patients threatened with amputation and without suitable autogenous saphenous veins. Distal anastomoses were to the tibial and peroneal vessels. Twelve patients (92 per cent) were discharged from hospital with functioning grafts; 9 grafts (69 per cent) continue to function 2-16 (average 8) months after operation. Amputation was avoided in 11 patients (85 per cent). Although early results are encouraging, late results are yet to be determined.

Small arterial reconstruction using modified cadaveric saphenous veins.

Human saphenous veins removed from cadaver donors were subjected to proteolytic enzymatic digestion, cross bonding, and heparin bonding. They were tested as small arterial substitutes in dogs. Eight of eleven were successful, persisting without development of stenosis or aneurysm, the longest for eighteen months. In humans, similarly prepared veins were used as arterial bypasses to revascularize ischemic limbs in eleven patients and aneurysmal degeneration of an earlier unmodified allograft bypass in one patient. Distal arterial anastomoses were to the tibial and peroneal arteries. Nine patients who had not undergone previous reconstructive surgery involving the vessel used for distal anastomosis were treated successfully; all remain with healed limbs between three and twelve months after surgery, eight with functioning bypasses. In three patients who had undergone previous operations on the same artery used for distal anastomosis, long bypasses failed, although amputation was avoided in one patient by additional bypass with modified vein to the profunda femoris artery. We conclude that modified saphenous vein allografts are suitable small arterial substitutes. It remains to be seen whether veins will maintain patency for long periods without development of complications.

Autogenous veins and velour dacron in femoropopliteal arterial bypass.

Sixty-five patients treated by femoropopliteal bypass in 1974 were surveyed; the mean follow-up time was 10.4 months. The one year cumulative patency rate for velour Dacron was 50 percent; this was less successful than were the results from a comparable group in which vein grafts were used (79 percent). These poor results were due principally to the high failure rate of velour Dacron in patients suffering from clinically severe ischemia. In these only one in four grafts remained patent. If a less than perfect arteriographic runoff was obtained, only one in three still functioned. These results occurred despite high intraoperative graft flows. It appears that velour Dacron may be acceptable in patients treated for claudication if no adequate vein is available. This prosthesis gives an unacceptably high failure rate in patients with severe ischemia.

Complications of intravenous therapy.

A survey of 130 patients receiving intravenous therapy was undertaken. There were no instances of speticaemia over this period, despite a positive bacterial culture rate for cannulae of 48%. The incidence of phlebitis was 31%, and was associated with usual physicochemical factors. These included a cannulation time of greater than two days, an intravenous potassium supplement and antibiotics. Normal saline solutions given alone were associated with a lower incidence of phlebitis and continuous intravenous heparin administration may prolong the period of cannulation before phlebitis occurs. The institution of intravenous therapy teams should help to minimize the complications.

Chronic gastric ulcer in the rat produced by wounding at the fundo-antral junction.

Standardized 8-mm mucosal wounds were made in the rat stomach at the rumeno-fundic junction, fundus, fundo-antral junction, and antrum, and examined at intervals up to 8 months. All wounds at the rumeno-fundic junction and fundus were healed within 4 weeks and at the antrum within 12 weeks. The majority of wounds at the fundo-antral junction remained chronic and at 8 months 41 of 50 rats still had ulcers 2 mm or greater in diameter. These findings suggest that the fundo-antral junction is an area which is susceptible to the development of chronic ulcers. This is a simple and reliable method of producing chronic gastric ulcers and does not alter the continuity or disturb the function of the gastrointestinal tract.

Tibial artery bypass.

Experience with 29 tibial bypasses is presented. Twenty-one have remained patent for an average time of 13.2 months. There were two hospital deaths and five additional late ones. Autogenous saphenous vein was used in 27. Electromagnetic flowmeter studies were useful in assessment of patency, but intraoperative arteriography was of limited value only. The use of peroneal artery had equivalent results to anterior and posterior tibial arteries. It is concluded that a reasonable limb prognosis may be offered to the patient with advanced ischemic disease and one or more open tibial vessels. The late mortality in this group is appreciable.

Heterotopic bone formation in abdominal scars.

Twelve patients with heterotopic ossification in abdominal scars have been studied. Two patients were elderly females. Operative excision was required in seven: two for local symptoms, two for suspected local malignant recurrences and three for further intra-abdominal procedures. The other five instances were diagnosed roentgenologically. The mechanisms of formation of such lesions are not clear, but both the implantation and metaplasia theories may be correct.