Bleeding from gastric antral vascular ectasia in marrow transplant patients.

BACKGROUND: Gastric antral vascular ectasia (GAVE) leads to blood loss in the disorders of "watermelon stomach" and portal gastropathy, but is not a commonly recognized complication of marrow transplantation. METHODS: GAVE was diagnosed when capillary ectasia, focal capillary thromboses, and fibromuscular hyperplasia were identified in antral mucosal biopsy specimens. Marrow transplant patients bleeding from GAVE were reviewed to ascertain common variables in their pretransplant, posttransplant, and bleeding course. RESULTS: Six patients developed bleeding due to GAVE. The onset of bleeding was 18 to 94 days after transplant and required an average of 37 U of blood (range, 2 to 130 U). Two patients stopped bleeding after restoration of platelet counts. Two patients had surgical antral resections; both died of multiorgan failure after surgery. Two patients had successful endoscopic laser ablation of vascular lesions and survived. Factors possibly associated with GAVE included male gender, VOD of the liver, oral busulfan as part of the conditioning regimen, and growth factor use after transplant. CONCLUSIONS: GAVE was a cause of gastric bleeding in six patients with marrow transplant patients. Restoration of platelet counts and endoscopic laser photocoagulation are the therapies of choice for ongoing bleeding in these patients.

Use of thoracoscopy in clinical practice.

Endoscopic surgery and, in particular, thoracoscopy, have become useful clinical tools as both technique and instrumentation have evolved. Our experience with a series of 20 patients undergoing thoracoscopy, including the indications, results, and outcome, is presented. Indications for thoracoscopy and biopsy or resection include the diagnosis and, in some cases, treatment of idiopathic pulmonary infiltrates, mycetomas, lung masses, spontaneous pneumothorax, and empyema. Morbidity is limited, and there has been no mortality due to the procedure.

Esophageal transection fails to salvage high-risk cirrhotic patients with variceal bleeding.

A small proportion of portal hypertensive patients with acute variceal bleeding do not respond to medical management and require emergency control of hemorrhage, yet are not candidates for shunt surgery. Transgastric esophageal transection and stapling of the esophagus has been suggested as a rapid, simple means to halt variceal bleeding in such high-risk patients. This should theoretically allow a hemorrhage-free interval for resuscitation and improvement in metabolic and cardiopulmonary status before definitive shunt surgery. We tested this hypothesis in 10 high-risk patients with variceal bleeding who underwent transection of the esophagus, sometimes with splenectomy and coronary vein ligation, over a 4 year period. In our experience, esophageal transection in high-risk patients with variceal bleeding controlled acute variceal hemorrhage, was neither rapid nor free of technical misadventures, was associated with a high rate of serious postoperative complications resulting in death in nearly all patients, and consistently failed to result in sufficient metabolic improvement to permit shunt surgery.

Ventilation and perfusion alterations following homologous blood transfusion.

A previous study in this laboratory examined the effect of micropore ultrafiltration of blood products on pulmonary gas exchange and subsequent pulmonary dysfunction--related morbidity and death. Morbidity and death from pulmonary failure was not affected; however, gas exchange was improved following ultrafiltration with 40 micrometers filters, as reflected by lower Bohr dead-space fractions. This difference might be explained by reduction of the microaggregate load seen in the pulmonary microvasculature. The purpose of this study was to examine in more detail these gas exchange alterations, paying particular attention to the correlation of changing Bohr dead-space ventilation detected with multiple inert gas analysis with direct determinations of microaggregate size and number. Fourteen patients with isolated cutaneous thermal injury scheduled for major early burn would excision were selected for study. Following transfusion with homologous blood products, the ventilation/perfusion ratio (Va/Q) distributions determined by inert gas analysis remained essentially unchanged except for subtle changes in both high VA/Q and dead-space compartments, resulting in significantly increased Bohr dead-space fractions (P less than 0.05). This combination of gas exchange alteration is consistent with vasoactive and occlusive changes in the pulmonary microvasculature following microaggregate infusion. The correlation of changing dead-space ventilation with the total microaggregate load was poor (r = 0.15) but was significant when compared with counts of microaggregates greater than 90 micrometers in diameter (r - 0.85). These findings suggest that gas exchange alterations following blood transfusion are primarily reflected by increased dead-space ventilation secondary to vasoconstriction and occlusion of the pulmonary microvasculature with microaggregates greater than 90 micrometers in diameter.

A prospective study of prophylactic penicillin in acutely burned hospitalized patients.

The use of prophylactic low-dose penicillin acutely burned, hospitalized patients remains controversial. Fifty-one adult patients with burns of 1% to 91% total body surface area were prospectively studied to determine the efficacy of prophylactic penicillin in the prevention of wound cellulitis and burn wound sepsis, and to examine the influence of prophylactic penicillin on the emergence of antibiotic resistant microorganisms. In 25 patients given a 5-day course of penicillin prophylactically, 11 developed cellulitis and two had burn wound sepsis. A similar group of patients given placebo developed seven cases of cellulitis and three cases of burn wound sepsis (p = 0.340). No patient in either group developed gentamicin-resistant Gram-negative organisms, although the gastrointestinal tracts of two patients in the penicillin group showed new colonization by yeast. We conclude that the routine administration of prophylactic penicillin neither protects against cellulitis and burn wound sepsis, nor promotes selection of antibiotic-resistant bacteria in hospitalized patients with acute thermal injury.

The burned hemophiliac.

Major surgical procedures are now performed with acceptable risk on patients with hemophilia A with pre- and postoperative anti-hemopilic Factor (AHF) infusions. However, there is almost no literature on care of the burned hemophiliac. We recently treated a patient with Factor VIII levels of less than 2% of normal and 45% TBSA burns. A forearm escharotomy was done with hemostatic protection by AHF infusion, but burn therapy, which included operative debridement and successful split-thickness skin grafting, was accomplished without the use of AHF. It is concluded that after early loading with cryoprecipitate, burned hemophiliacs do not require continued AHF, because repair and restoration of vascular integrity in small vessels may occur due to platelet plugging and vessel retraction. Tissue thromboplastin may also contribute to clotting in burned hemophiliacs.

Laser scalpel for solid organ surgery.

Hemostasis remains a major technical problem in surgery of the liver and spleen. A high power neodymium-doped yttrium aluminum garnet (Nd:YAG) laser has been coupled with a fiberoptic delivery system and quartz blade designed to yield maximal hemostasis and minimal tissue injury. In a series of experiments we were unable to demonstrate a significant advantage of its use in partial hepatic lobectomy.

Burn injury in infants and young children.

Scalding, most often self-precipitated, is the most common cause of burn injuries in children. Flame burns are much less common but are more severe and have a higher mortality than do scalds. Most burns in this age group are small, but affect areas functionally and cosmetically sensitive to burn injury. Abused infants and toddlers have a much higher mortality than do unabused children. Younger children have a higher mortality after serious burns than do older children. Common infections include otitis media, viral gastroenteritis and viral infections of the upper part of the respiratory tract, many of which are established prior to injury. Hyperthermia and leukocytosis are common and may be misleading as indicators of infection. Fluid needs are greater than predicted by the Parkland formula. Hypertension is uncommon and resolves spontaneously.

Effect of micropore filtration on pulmonary function after massive transfusion.

1. This study demonstrates a positive correlation between the number and size of infused microaggregates and the subsequent abnormality in pulmonary function as measured by oxygenation and dead space. 2. No such correlation between the severity of injury and the altered pulmonary function or transfusion volume was demonstrated. 3. We were unable to demonstrate an advantage to the use of a 40 mu micropore filter in preventing the adult respiratory distress syndrome (ARDS) or in improving pulmonary function in our patients. 4. One explanation for the failure to demonstrate such an advantage is the low efficiency of the filter used.