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.

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.