Bleeding varices of the small bowel as a complication of pancreatitis: case report and review of the literature.

A case of a 48 year old male with a history of alcohol abuse, chronic relapsing pancreatitis, and massive hemorrhage into the small intestine is reported. The patient had previously undergone a cholecystojejunostomy. Imaging studies demonstrated occlusion of the splenic, superior mesenteric, and distal portal veins with large varices in the jejunum. He recovered following jejunal resection and Roux-en-Y cholecystojejunostomy. The mechanism for formation of varices in the small bowel in this clinical setting is discussed.

Acute pancreatitis following aortic aneurysm repair: report of three cases.

This paper reports three cases of acute pancreatitis that occurred after repair of an abdominal aortic aneurysm. The aneurysms were ruptured in two patients and asymptomatic in one. No patient had biliary disease or history of pancreatitis or alcohol abuse. Two of the patients required operation for drainage and debridement; one died. The etiology and diagnosis are discussed.

Division of the left renal vein during aortic surgery.

Perirenal aortic exposure and control can be facilitated by division of the left renal vein (LRV), but only if adequate collateral venous drainage is present. When incremental elevations in LRV pressure were produced in nine dogs, we noted that left renal glomerular and tubular function (creatinine clearance, sodium retention, urine osmolality, and urine output) were virtually lost at pressures greater than 50 to 60 cm water. Between January 1967 and December 1989, 64 patients underwent LRV division during the performance of abdominal aortic aneurysm surgery (57 of 589 = 10%) or reconstruction for aortoiliac occlusive disease (7 of 506 = 1%). LRV stump pressures (LRVSPs) were measured in 44 of these patients and were less than or equal to 60 cm water in all but one instance. Ten of the 64 patients died, but none as a consequence of this maneuver. Post-operatively, all survivors had serial serum creatinine levels measured and either an intravenous pyelogram, renal scan, or arteriogram. One case of a non-functioning left kidney was identified. This occurred in the only patient who underwent re-anastomosis after LRV division. A LRVSP equal to or greater than 50 cm water and extreme venous distention after test clamping served as a contraindication to LRV division in seven other patients. We conclude that a LRVSP less than or equal to 50 to 60 cm water indicates that the LRV may be safely divided during juxtarenal aortic exposure. However, a pressure greater than or equal to 50 to 60 cm water suggests that LRV division should not be carried out unless absolutely essential and then only if right kidney function is known to be adequate.

Reoperation for glioblastoma.

The results of a second operation for tumor removal in 24 adult patients with supratentorial glioblastoma multiforme or anaplastic astrocytoma were analyzed. The median survival time after reoperation was 14 weeks. Five of the 24 patients lived 6 months or longer after reoperation. Only three of these patients maintained a Karnofsky rating (KR) of at least 60 for 6 months or longer after reoperation. Preoperative neurological status (KR) is the most significant determinant of survival after reoperation (p = 0.02). When the KR is at least 60, median survival after reoperation is 22 weeks. When the KR prior to reoperation is less than 60, median survival is 9 weeks. Only one of 13 patients with a KR of less than 60 prior to reoperation survived longer than 6 months after the second operation. The interval between first and second operation is significantly related to survival (p = 0.03), but when adjustment is made for the KR the interoperative interval is no longer significantly related to survival after the second operation (p = 0.39). Age, sex, and location of tumor were not significantly related to duration of survival. This study suggests that reoperation is most likely to produce the best result when the KR is at least 60 and the interval between operations is longer than 6 months. Using these criteria, one-third of the patients could be expected to survive with a KR of at least 60 for 6 months. The study indicates that reoperation should not be carried out when the KR is less than 60.

Division of the left renal vein. Guidelines and consequences.

Ligation and division of the left renal vein is a reasonable safe procedure in selected patients when exposure of the perirenal aorta is crucial. This manipulation is possible because of extensive venous collateralization from the left kidney in man. Measurement of the venous stump pressure before ligation is recommended to assess the degree of collateralization, and the upper limit within which the vein may be divided safely is probably in the neighborhood of 60 cm of water. Reanastomosis of the vein is not necessary for preservation of renal function, although transient left renal dysfunction may occur. Examination of the urine and careful monitoring of renal function should be routine in the postoperative period. Intravenous urography and left spermatic venography later in the postoperative course can indicate the ultimate degree of function of the left kidney and the pathways of venous collateralization. Preservation of normal function and venous architecture at the renal hilum should be the rule.

Results of 100 consecutive femoropopliteal vein grafts for limb salvage.

One hundred consecutive patients with femoropopliteal autogenous vein grafts for limb salvage were reviewed five years later. In this group 40% died and 30% of the limbs had been lost at the end of five years. Limb survival correlated best with adequacy of distal run-off, but not with the presence or absence of diabetes. Forty-seven per cent of the grafts were still patent among surviving patients, and when combined with the limbs that were viable despite failure of the original graft, 70% of the limbs were salvaged among the survivors at five years. Temporary graft patency was effective in preserving ischemic tissue by facilitating healing of ulcers or limited amputations. Femoral-popliteal bypass grafting in the presence of advanced ischemia is capable of improving the quality of life for many of these patients.

Adrenergic blockade and renal hemodynamics.

An isolated blood perfused kidney preparation was used to study the influence of intrarenal adrenergic receptors on renal hemodynamics, renal function, and the renin-angiotensin system. Beta adrenergic blockade with propranolol resulted in a reduction of fractional sodium excretion, and alpha blockade with phentolamine had no effect on sodium excretion despite significant increases in cortical flow and glomerular filtration rate. The changes in sodium excretion after beta blockade were not felt to be due to a direct tubular effect but rather were secondary to preferential perfusion of nephrons in the juxtamedullary cortex, which is known to have higher sodium reabsorptive capacity. These changes appeared to be direct effects of adrenergic blockade on the renal vasculature and were independent of any effects on renin secretion.

Operative management of renovascular hypertension.

From 1966 to 1975, 38 patients underwent 42 procedures for renovascular hypertension; 35 operations were aortorenal bypasses and 7 were nephrectomies. Forty-five per cent of the patients were cured, 43% were improved and 12% were unimproved. There were no operative deaths and only three late deaths. Two grafts occluded and 2 became stenotic, giving a graft complication rate of 12%. Curability was best correlated with a short history of hypertension and a pathologic diagnosis of fibromuscular hyperplasia, but not with patient age. Most patients selected for surgery had elevated renal venous renin ratios, and of these 95% were cured or improved. Of those with normal renin ratios, 85% were still cured or improved. Postoperative aortography and peripheral renin measurements offered valuable information in predicting the ultimate response to surgery. Preservation of renal function was a principal indication for surgery in 11 patients. In 8, azotemia was documented preoperatively. Hypertension was cured or improved in every case and 5 patients demonstrated a 10-50% reduction in BUN and creatinine following revascularization.

Evidence for modification of protein phosphorylation by cytokinins.

Kinetin stimulated phosphorylation of protein in floated Chinese-cabbage leaf discs, but inhibited protein phosphorylation in nuclei+chloroplast extracts from Chinese-cabbage or tobacco leaves. Kinetin also inhibited protein phosphorylation in isolated tobacco nuclei or nuclei from carrot secondary-phloem tissue. Purified Chinese-cabbage leaf ribosomes exhibited protein kinase activity which was inhibited by kinetin and zeatin. The ribosome-associated kinase responded to kinetin and zeatin differently from that associated with nuclei+chloroplast preparations. Protein phosphorylation in vitro was not affected by adenosine 3':5'-cyclic monophosphate, indol-3-ylacetic acid or gibberellic acid. It was only inhibited by N(9)-unsubstituted purines, among which the known cytokinins were the most effective inhibitors. The results are discussed in relation to possible similarities between the effects of cytokinins in plant tissues and the effects of adenosine 3':5'-cyclic monophosphate in animal tissues. Both compounds appear to modify the activity of protein kinases and both affect many different cellular processes.

Protein, nucleic acid and starch metabolism in the duckweed, Spirodela oligorrhiza, treated with cytokinins.

Bacteria-free cultures of Spirodela oligorrhiza continue to increase in frond number for 2 to 3 days after transfer to darkness. There is then no further increase in frond number for 3 to 4 weeks, although DNA, RNA and protein synthesis continue at decreased rates and starch accumulates in the plants. We refer to such ;non-growing' plants in darkness as dormant. Adding kinetin to dormant Spirodela initiated increased DNA, RNA and protein synthesis within 1h, although new fronds were not detected until 24h after the addition of kinetin. The frond number then continued to increase. Starch accumulated in dormant plants. Accumulation of starch appeared to be a consequence of inhibition of growth rather than the converse. No evidence was obtained for a block in [(14)C]glucose metabolism that might explain the lack of growth in darkness in the absence of kinetin. In darkness, more ribosomes were membrane-bound in dormant Spirodela than in Spirodela growing with kinetin. Similarities between the response of Spirodela to darkness, stringent control in bacteria and pleiotypic controls in animal cells are discussed. It is suggested that all three processes are ultimately controlled by specific protein kinases that are individually sensitive to different effectors.

Cytokinin control of growth of Spirodela oligorrhiza in darkness.

Continuous heterotrophic growth of Spirodela oligorrhiza cultures following transfer to darkness requires cytokinins, or periodic brief treatment with red light. In the absence of cytokinins or red light growth ceases after 2-3 days. However, growth resumes spontaneously after 3-4 weeks in darkness to produce etiolated plants. The growth rate of these etiolated plants is not stimulated by kinetin.Although the kinetin concentration in treated plants reaches a plateau 30-60 min after adding kinetin to "dormant" plants in darkness new fronds do not appear for 24 h. Dormant colonies treated with kinetin in darkness for only 6-12 h subsequently grow in darkness at the same rate as plants treated with kinetin for 1, 2 or 3 days. Treatments which inhibit growth in the light, for example cold, chloramphenicol or actidione, eliminate the requirement for cytokinin and allow subsequent growth in darkness. The results suggest that a growth inhibitor may be present but ineffective in Spirodela growing in the light. The inhibitor is active in darkness but slowly decays. Kinetin appears to inactivate the inhibitor in darkness.