Proctitis cystica profunda in paraplegics. Report of three cases.

Proctitis cystica profunda is a benign disease of the rectal mucosa that can be mistaken for rectal carcinoma both grossly and microscopically. Symptoms may consist of blood or mucus in the stool, diarrhea, tenesmus, or rectal pain. The disease has never been reported in a paraplegic population before, but the proposed etiology makes this group seem to be at high risk. We report three cases in our paraplegic population and discuss the nature of the disease as well as its treatment.

Combined transluminal angioplasty and infrainguinal reconstruction in multilevel atherosclerotic disease.

Patients with multilevel atherosclerotic disease represent a difficult surgical challenge. This report is a retrospective review of 46 patients who were treated using a combination of iliac transluminal angioplasty and infrainguinal reconstruction. There were 42 male and 4 female patients with an average age of 62 years (range: 40 to 74 years). Follow-up ranged from 1 month to 10 years (mean: 27.3 months). These patients had multiple health problems typical of patients with peripheral vascular disease, including coronary artery disease (67%), hypertension (61%), and diabetes mellitus (42%); 80% of the patients were smokers. Forty-one patients were treated for rest pain and/or tissue loss, while five were treated for incapacitating claudication. Forty-three patients had a combination of angioplasty and distal bypass, while 3 patients had a form of femoral endarterectomy. Iliac artery pressure gradients were reduced from 35.4 +/- 4 mm Hg preangioplasty to 0.6 +/- 0.3 mm Hg postangioplasty. The procedures were well tolerated with no mortality and four serious complications. Vascular laboratory studies showed an improvement in the mean ankle-brachial index from 0.35 +/- 0.03 preoperatively to 0.71 +/- 0.04 postoperatively (p less than 0.05). Life-table analysis revealed a 72% 5-year primary patency rate, with a 93% 5-year limb salvage. Eight patients required a secondary procedure to maintain limb salvage. Five patients underwent amputation, three due to early graft thrombosis and two due to late graft failure. We conclude that combined iliac angioplasty and infrainguinal reconstruction is a safe and effective method for managing the patient with severe multilevel atherosclerotic disease.

Alterations in biliary motility correlate with increased gallbladder prostaglandin synthesis in early cholelithiasis in prairie dog.

Abnormal biliary motility has been observed in humans with gallstones and in animal models; however, the mechanism by which these abnormalities occur remains unknown. In this study we investigated the relationship between cholesterol gallstone formation, changes in biliary motility, and rates of gallbladder prostaglandin synthesis in prairie dogs receiving a 0.34% cholesterol diet for two, four, or six weeks. Gallstones did not occur until four weeks, when the incidence was 14%; after six weeks the incidence was 64%. Gallbladder emptying increased slightly at two weeks before becoming significantly decreased at four and six weeks. In contrast, there was a near linear increase in basal cystic duct resistance which began by two weeks of cholesterol feeding, although sphincter of Oddi resistances remained normal throughout the period of study. The synthesis of prostaglandins E and F2 alpha by the gallbladder was also increased beginning at two weeks and rose to a plateau at four and six weeks. In view of the potent effects of prostaglandins on biliary smooth muscle, these findings suggest that prostaglandins may mediate early changes in gallbladder and cystic duct motility which ultimately result in impaired gallbladder emptying.

Runoff resistance and early graft failure in infrainguinal bypass surgery.

Recent reports suggest that intraoperatively measured runoff resistance can identify patients destined for early graft failure. We measured runoff resistance in 80 consecutive patients who had undergone infrainguinal bypass surgery, and periodically assessed graft patency. There were 57 femoropopliteal bypass grafts and 23 infrapopliteal bypasses. After 3, 6, or 12 months, there was no significant difference in mean resistance between those grafts remaining patent and those that failed. Moreover, among patients with very high resistance (greater than 1.2 mm Hg/mL/min), 12 bypass grafts remained patent for more than one year. These results demonstrate that even patients with relatively high runoff resistance can undergo successful bypass grafting. Consequently, patients with measured or angiographic evidence of poor runoff should not be denied vascular reconstruction on this basis alone. We believe that graft failure is a multifactorial process in which the nature of the graft material, location of the distal anastomosis, runoff resistance, and a number of other factors are likely to play a role.

Evaluation of a proposed standard reporting system for preoperative angiograms in infrainguinal bypass procedures: angiographic correlates of measured runoff resistance.

Preoperative angiography is widely used to estimate runoff before peripheral vascular bypass surgery. The Ad Hoc Committee on Reporting Standards for the Society for Vascular Surgery and the International Society for Cardiovascular Surgery recently proposed an angiographic scoring system that grades the quality of vessels distal to the proposed bypass site and calculates an overall runoff score after adjusting each vessel score by an arbitrary weighting factor. We compared this score with intraoperatively measured runoff resistance in 67 patients undergoing infrainguinal bypass. Correlation between overall runoff score and measured resistance varied with the distal bypass site and was reasonably predictive for femoropopliteal above-knee bypasses (r = 0.67, p = 0.004, N = 17) and femoroposterior tibial bypasses (r = 0.73, p = 0.03, N = 9), but not for femoropopliteal below-knee (r = 0.05, p = 0.76, N = 34) or femoroperoneal (r = 0.57, p = 0.18, N = 7) bypasses. When multiple linear regression was used to calculate the weighting factors (rather than using arbitrarily assigned factors), the correlation between overall angiogram score and measured resistance improved substantially for femoropopliteal above-knee (r = 0.85, p = 0.00006), femoropopliteal below-knee (r = 0.50, p = 0.03) and femoroperoneal (r = 0.83, p = 0.02) bypasses. Correlation for the entire group of 67 patients improved from r = 0.30 (p = 0.02) to r = 0.64 (p = 0.0001). We conclude that the committee's scoring system correlates with measured runoff resistance but can be improved by the use of multiple linear regression to calculate weighting factors for each vessel in the outflow tract.