Four-year patency of PTFE grafts after replacement of the superior vena cava and the innominate veins.

We describe a simpler alternative to treating vena cava syndrome with composite spiral vein grafts. Instead, we used 2 polytetrafluoroethylene (PTFE) grafts to replace the resected superior vena cava and innominate veins of a man with a malignant thymoma. Both grafts have remained patent more than 4 years after surgery, and the patient has continued asymptomatic and free of malignancy. Therefore, we recommend using PTFE grafts to replace the great veins of the thorax.

Implantation of pericardial substitutes.

Pericardial substitutes have been shown to decrease the formation of pericardial adhesions. For a pericardial substitute to be properly implanted, it must lie over the heart smoothly without buckling and prevent the accumulation of blood under its surface. The technique we describe prevents buckling of the pericardial substitute and consequently reduces the formation of pericardial adhesions.

Mersilene ribbon closure of the median sternotomy: an improvement over wire closure.

With the increased utilization of median sternotomy in thoracic surgery, some difficulties have arisen with closure of the sternum. This article presents a simple, easy-to-perform method of sternal closure utilizing reinforcement of the sternal halves with a material that is less likely to cut through the sternum and that is readily available.

Simplified aortic cannulation.

Cannulation of the ascending aorta for cardiopulmonary bypass can be complicated by excessive bleeding or improper (too low) placement. A simple method of cannulation that avoids these problems is presented. This technique has been utilized in more than 1,000 patients without untoward complications.

Surgical experience with expanded polytetrafluoroethylene (PTFE) as a replacement graft for traumatized vessels.

With the increased nationwide incidence of major vascular injuries, the need for interposition grafting has become quite common in major trauma centers. Despite extensive experience with such injuries, the choice of a substitute conduit remains controversial. Recent studies have demonstrated the potential of expanded polytetrafluoroethylene (PTFE) as a replacement graft for small arteries and veins. The surgical services at the Ben Taub General Hospital began to use PTFE grafts in traumatic vascular wounds approximately 2 years ago. Eight axillary arteries and 12 brachial arteries have had interposition grafting with PTFE prostheses. Eleven patients have required PTFE interposition grafts in repair of traumatized common, superficial, and profunda femoris arteries and common femoral veins; eight patients had reconstruction in the popliteal artery or vein. Three patients had renal artery revascularization procedures following blunt abdominal trauma, three patient had segmental replacement of the superior mesenteric artery following gunshot wounds, and one carotid artery, one iliac vein, and two axillary veins were grafted with PTFE. All patients with segmental repair of axillary, brachial, femoral, and popliteal vessels have maintained good distal pulses and viable extremities. No grafts have thrombosed, nor become infected, in spite of soft-tissue injury encountered at time or repair. In situations requiring interposition graft placement for reestablishment of distal flow in small arteries and veins, PTFE grafts appear to be an acceptable prosthesis.

Combined pancreatoduodenal injuries.

Operative management of combined pancreatic and duodenal injuries has been a controversial subject in recent years. Methods advocated include resection, duodenal diversion, and simple repair and drainage. Excellent results have been reported with each of these, but most reported series are small, preventing definitive conclusions concerning the value of any treatment modality. During an 8-year period ending December 1976, 308 pancreatic injuries and 175 duodenal injuries were treated. Sixty-eight of the patients had combined pancreatic and duodenal injuries and constitute the basis for this report. Fifty-five patients sustained penetrating injuries and 13 had blunt injuries. Eighteen underwent repair and drainage. The remaining 50 required more extensive procedures which included duodenal diversion and pyloric exclusion in 32, pancreatoduodenectomy in six, and a variety of procedures in the remainder. The operative mortality rate was 26.4%, including five patients who died intraoperatively. In the entire series only one death was directly attributable to the pancreatoduodenal injury. We conclude that no single procedure is uniformly applicable to these injuries. Surgeons treating trauma of this severity should be familiar with a variety of techniques for repair, and treatment should be individualized. Preservation of tissue should be accomplished when possible.

The use of pyloric exclusion in the management of severe duodenal injuries.

Repair of severe duodenal injuries often constitutes a technical challenge, and a variety of special technics have been described. For the past seven years we have utilized temporary pyloric exclusion and gastrojejunostomy to produce "diverticulization" of the duodenum. This procedure was utilized in seventy-five patients selected from 175 consecutive patients presenting with duodenal trauma. The mortality was 19 per cent and the rate of fistula formation was 5 per cent in this series and 14 per cent and 2 per cent, respectively, in the overall series. Follow-up studies of gastric physiology and functional anatomy show no evidence of alteration of these parameters. We thus believe that patients presenting with severe duodenal trauma and often multiple devastating associated organ injuries can be adequately treated with this procedure with a significant decrease in mortality and with marked improvement of postoperative morbidity.

Systemic air embolism following penetrating trauma to the lung.

Systemic air embolism following penetrating injuries of the lung has not been widely recognized clinically. Experimental studies designed to reproduce the phenomenon in dogs have been at variance, although none has taken into consideration the often high intrabronchial pressures created during resuscitative efforts in such patients. Twelve patients with systemic air embolism following penetrating traumatic injuries to the lung have been seen at our hospital. Ventilatory pressures created during resuscitative thoracotomy in traumatized patients were monitored and found to be as high as 100 mm Hg. Penetrating injuries of the lung were created in mongrel dogs, and the animals were ventilated with pressures reaching 90 mm Hg. All dogs unequivocally developed systemic air embolism, with air visualized in the coronary arteries. It would appear that systemic air embolism following penetrating injury to the lung may result when increased intrabronchial pressure, such as found during manual ventilatory assistance, forces air through traumatic bronchovenous fistulae into the systemic circulation.

Dynamics of insulin release and microtubular-microfilamentous system. I. Effect of cytochalasin B.

In order to assess the participation of the microfilamentous cell web in the multiphasic response of the pancreatic beta cell, the effect of cytochalasin B upon both glucose- and sulfonylurea-induced insulin release was investigated in the perfused isolated pancreas. Cytochalasin B failed to affect the basal rate of insulin release, but enhanced the initial and later phases of insulin secretion in response to either glucose or gliclazide. In addition, cytochalasin B lowered the threshold concentration for the stimulant action of glucose upon insulin release. Ultrastructural studies supported the concept of a specific interaction of cytochalasin B with the microfilamentous cell web of the beta cell. It is concluded that the integrity of such a structure is equally important for both the initial and later secretory responses of the beta cell to various insulinotropic agents.