Intraoperative pressure measurement in radial artery harvest. A tool with additional value?

OBJECTIVES: The radial artery is widely used as a graft in coronary artery bypass surgery (CABG). Due to its location and function it should be screened prior to harvesting to avoid ischaemic complications of the hand. In acute situations the Allen test is often the only preoperative screening method available. As has been noted earlier, a negative Allen test does not mean a non-harvestable radial artery. We endeavoured to find out whether intraoperative pressure measurement could be used as a complement while screening the radial artery. DESIGN: Ninety patients planned for elective CABG with radial artery as a conduit were examined preoperatively with the Allen test, handheld Doppler and pletysmography of the second and fourth digits. Radial artery pressure was measured intraoperatively. Symptom scale was recorded pre- and postoperatively. RESULTS: There were ten patients with a positive Allen test. The intraoperative index of radial artery pressures was 0.868 in the Allen positive group and 0.885 in the Allen negative group with no statistically significant difference (P value .68). Tolerance of exercise and cold was significantly impaired postoperatively, P values .002 and .001 respectively. No ischaemic complications occurred. CONCLUSIONS: Intraoperative pressure measurement can be used when screening radial arteries are to be harvested and no metric preoperative screening methods are available.

Antireflux surgery enhances gastric emptying.

OBJECTIVE: To evaluate the influence of antireflux surgery on gastric emptying. DESIGN: Nonrandomized controlled trial 3 months before and after surgical intervention. SETTING: Secondary and tertiary referral center. PATIENTS AND CONTROL SUBJECTS: Twenty consecutive patients (7 women, 13 men), mean age 49.2 years, with symptomatic, objectively confirmed gastroesophageal reflux disease and 10 healthy control subjects (3 women, 7 men), mean age 37.3 years. INTERVENTION: Laparoscopic or open Nissen fundoplication (in 1 case Toupet 180 degrees posterior hemifundoplication). MAIN OUTCOME MEASURES: Gastric emptying scintigraphy, using solid food, in control subjects and patients 3 months before and 3 months after the operation; time to halving of the maximal activity and the activity remaining at 60, 100, and 120 minutes. RESULTS: Preoperative symptoms included pyrosis in 19 of 20 patients and regurgitation in 18. Three months postoperatively, 19 patients were symptom-free. The mean time to halving of the maximal activity decreased from 113 to 78 minutes (P = .001). Delayed gastric emptying was found postoperatively in 3 patients, compared with preoperative values, using activity at 60, 100, 120 minutes and the mean time to halving of the maximal activity as the variables. Compared with control subjects, gastric emptying was slower in patients preoperatively and faster postoperatively, but the difference was not statistically significant. CONCLUSION: Gastric emptying is enhanced after antireflux surgery, along with cessation of symptoms and healing of esophagitis.

Atherosclerosis of the inferior epigastric and internal mammary arteries.

Atherosclerosis of the inferior epigastric artery (IEA) and the internal mammary artery (IMA) was evaluated in 21 patients with coronary heart disease. Both arteries were used simultaneously in coronary artery bypass grafting. Histologic samples were obtained from the proximal and distal segments of IEA and from the distal segment of IMA. Morphologic findings in regard to atherosclerosis were classified semiquantitatively as normal (0), or luminal narrowing <25% (1), 25-50% (2) or >50% (3), or as overt atherosclerosis and calcification (4). Atherosclerosis was absent or minimal (1) in distal samples from both arteries. Only one IMA showed moderate (2) luminal atherosclerotic obstruction. Two samples from proximal IEA showed moderate (2) or severe (4) atherosclerotic changes which limited their use as free grafts. These finding suggest that atherosclerosis is minimal and comparable in distal IEA and IMA in their natural environments even in patients with coronary heart disease. The long-term effect of aortic pressure on free IEA graft is still unclear.

Inferior epigastric artery as a conduit for myocardial revascularization.

In 18 patients the inferior epigastric artery (IEA) was used for myocardial revascularization along with the left internal mammary artery and saphenous vein (4.5 grafts/patient). Preoperative duplex scan assessment of IEA correctly predicted its distal diameter. At operation the mean internal diameter was 1.6 (1.5-2.0) mm distally and 2.1 (2.0-2.5) mm proximally. The mean in situ flow after intraluminal injection of papaverine was 115 (36-210) ml/min in IEA and 136 (56-210) ml/min in internal mammary artery. There was no perioperative death or myocardial infarction. Morbidity associated with IEA harvesting was minor: ultrasonography showed diastasis and slower contraction of the rectus muscle at the harvesting site than contralaterally in one case. The preoperative duplex scan was useful for evaluating IEA size. All the patients were clinically improved. The patency rate at selective IEA angiography 3 months post-operatively was 72% (13/18). This poor early patency of IEA in our small series raises doubts concerning the vessel's suitability for myocardial revascularization.

Traumatic luxation of the heart.

A case of luxation of the heart resulting from blunt thoracic trauma is presented. Pericardial defect with herniation of the heart was discovered preoperatively and successfully repaired with a pleural patch. Special attention is drawn in the report to the preoperative diagnosis of this life-threatening condition.

High volume lesser sac lavage in acute necrotizing pancreatitis.

The effect of lesser sac drainage with or without lavage on some early predictors and on outcome in acute necrotizing pancreatitis was analysed. The evaluation was made prospectively for 24 patients, in a single centre study. According to Ranson's criteria and laparotomy findings, the lavage and drainage groups were comparable and the pancreatitis was severe and necrotizing in both groups. In a longitudinal analysis of the first 4 postoperative days, lavage did not show any advantage over drainage, as measured by seven prognostic signs (serum creatinine, blood glucose, base excess, haematocrit, white blood cells, C-reactive protein and immunoreactive phospholipase A2 concentration). Furthermore, the study did not find that lavage had any positive effect on the incidence of mortality (36 versus 17 per cent in the drainage group) or on septic complications in acute necrotizing pancreatitis. In the total series the extent of pancreatic necrosis was an essential predictor of the outcome.

Human pancreatic phospholipase A2 in acute necrotizing pancreatitis.

The activity and the content of phospholipase A2 (PLA2), a potential 'toxin' in pancreatitis, were determined separately by respective methods in pancreatic tissue resected from 22 patients treated for acute necrotizing pancreatitis. Correspondent enzyme assays were analyzed in the serum of 6 last patients. In cases with total necrosis in the tissue resected, the pancreatic PLA2 activity, but not the content, was almost totally lost. Serum PLA2 activity slightly decreased within the extension of pancreatic necrosis. The timing of sampling, number of positive Ranson signs or the course of the disease had no influence on the tissue PLA2 results. Serum PLA2 activity showed a correlation with tissue PLA2 activity.

ERCP in evaluating the mode of therapy in pancreatic pseudocyst.

Twenty patients with ultrasonographic or computed tomographic diagnosis of pancreatic pseudocyst were referred for endoscopic retrograde cholangiopancreatography (ERCP). Two of these were found at laparotomy not to have pseudocysts and were excluded. Pancreatography was successful in 15 out of 18 cases (83%) and cholangiography in 12 out of 18 cases (67%). Three types of pseudocysts were noticed according to the communication of the pseudocyst to the main pancreatic duct and the presence of pancreatic duct stenosis. Successful treatment included two spontaneous resolutions, two internal drainages and three left pancreatic resections. In the eight percutaneous external drainages four recurrences (50%) occurred, one after closure of temporary pancreatocutaneous fistula. All the recurrences occurred in Type III pseudocysts with communication of the pseudocysts to stenotic main pancreatic duct. In these cases internal drainage would have been the preferable treatment method. We believe that by ERCP one can identify pseudocysts not suitable for external drainage.

Influence of pancreatic resection on systemic complications in acute necrotizing pancreatitis.

The influence of pancreatic resection on early systemic complications of acute necrotizing pancreatitis was evaluated in 84 patients. The aetiology of pancreatitis was alcohol 71 per cent, gallstones 13 per cent, alcohol plus gallstones 2 per cent, trauma 1 per cent and idiopathic 12 per cent. A total of 26 of 81 patients (32 percent) had greater than 50 per cent pancreatic necrosis and 9 patients (11 per cent) considered to have parenchymal necrosis at operation had none shown histologically. The overall mortality was 38/84 (45 per cent) and mortality during the first postoperative week was 15/84 (18 per cent). The outcome after early and delayed operation did not differ significantly. Pancreatic resection had no beneficial effect on shock or respiratory or renal failure (respective pre-operative incidence 12 per cent, 11 per cent and 14 per cent).

Pancreatic remnant abscess after resection for acute necrotising pancreatitis.

Pancreatic resection for acute necrotising pancreatitis was followed by abscess of the remnant in 14 out of 83 cases. Not even extensive pancreatic resection could prevent pancreatic remnant infection. The 14 cases of abscess are reviewed. Seven were fatal. Enterocutaneous fistula, commonly accompanied by sepsis and major bleeding, was identified in five patients, four of whom died.

Ranson signs and necrosis of the pancreas in acute necrotising pancreatitis.

The value of Ranson signs as an indicator of the extent of pancreatic parenchymal necrosis in acute pancreatitis was investigated in 84 patients. Ranson signs could be compared with histologic extent of pancreatic necrosis in 69 cases. The overall mortality rate was 38/84 (45%). The mortality risk increased with the number of positive Ranson signs (correlation coefficient 0.96). The mean total of Ranson signs showed linear increase with extent of parenchymal necrosis up to 75% (from 2.9 signs at no necrosis to 5.4 signs at 75% necrosis, but only 4.7 signs at 76-100%). A similar relationship was found between extent of necrosis and mortality rate. Although the number of positive Ranson signs correlated with the extent of necrosis in resected pancreas (coefficient 0.96), the signs did not adequately predict necrosis in total pancreas. Ranson criteria can be accepted as prognostic signs even when acute necrotizing pancreatitis is treated with resection. The Ranson factors also correlate with necrosis, but do not alone reliably establish its extent in individual cases.

C-reactive protein (CRP) and pancreatic necrosis in acute necrotising pancreatitis.

C-reactive protein (CRP) was measured on the operation day in 35 patients with acute necrotising pancreatitis. In this prospective study the CRP level differentiated with high significance (p less than 0.001) the patients with extensive pancreatic necrosis from the patients with limited pancreatic necrosis. A marked variation in CRP production was demonstrated in both groups. Therefore in individual cases CRP alone is not a reliable predictor of pancreatic necrosis.

Lactoferrin in acute necrotizing pancreatitis.

Lactoferrin, as measured in the pancreatic juice, has been thought to be of diagnostic value in chronic pancreatitis, but due to the hazards in cannulation of the pancreatic duct in the acute phase of pancreatitis the behavior of lactoferrin has remained obscure. In this study, lactoferrin levels were studied in pancreas tissue specimens obtained in ablative surgery for acute necrotizing pancreatitis (ANP) and in serum samples. A higher pancreatic lactoferrin content was found in ANP than in normal pancreas. Lactoferrin seemed not to leak from a necrotic pancreas in any considerable amounts into the circulation, as no differences were found in serum lactoferrin concentrations between ANP and controls. It remains an open question whether the lactoferrin increase is only an unspecific reaction in inflammation or is something specific for pancreatitis.

Hepatic coma resulting from diaphragmatic rupture and hepatic herniation.

We treated a unique case of blunt rupture of the right hemidiaphragm that produced acute hepatic failure with jaundice and coma. Laparotomy showed total eventration of the liver into the chest. The hepatic failure was caused by strangulation of the extrahepatic biliary and venous structures. Surgical repair was followed by recovery and normalization of hepatic function. This case stresses the need to diagnose and treat diaphragmatic ruptures promptly to prevent such threatening complications. The diagnosis of right diaphragmatic rupture must be suspected in instances of blunt injury, with an awareness of misleading presentations.

Surgical treatment of pancreatic pseudocysts. A review of 42 cases.

21 years' experience of operated pancreatic pseudocysts is reviewed. The number of patients was 42, with mean age of 50 +/- 5 years. Thirteen patients (31%) were alcoholic. In 6/42 cases (14%) pancreatic carcinoma was considered the reason for pseudocyst formation. In 30 patients an internal and in 11 an external drainage was created. Operative mortality occurred in 3 patients (7%). External drainage was effected in patients with complicated pseudocyst. The complication rate in this group was 6/11 (55%) and in the internal drainage group 7/30 (23%). Internal drainage is a safe and effective procedure in patients with a mature pseudocyst wall. External drainage should be used in patients critically ill or with an immature pseudocyst wall.