Assessment of donor limb hemodynamics in femorofemoral bypass for claudication.

During a 5-year period (1975 to 1980), 44 patients underwent femorofemoral bypass for unilateral disabling claudication caused by iliac atheroocclusive disease. All patients had complete Doppler arterial examination performed pre- and postoperatively, including segmental thigh and ankle pressure and calculation of an ankle/brachial (A/B) index for each limb. In 37 patients, standard treadmill exercise testing was performed before and after femorofemoral grafting. Hemodynamic improvement in the symptomatic limb was evidenced by an increase in resting A/B index from a mean of 0.54 +/- 0.14 before to 0.76 +/- 0.22 after operation (P less than 0.001). Exercise tests which were abnormal in all 37 recipient limbs preoperatively were improved. Six of the seven unimproved recipient limbs had associated femoropopliteal occlusion. Donor limb mean resting ankle/brachial index fell from 0.93 +/- 0.22 before to 0.83 +/- 0.22 after surgery (P less than 0.05). However, in 13 of 23 donor limbs, exercise response which had been normal before surgery became abnormal. Additionally, in 14 patients with abnormal donor limb exercise response before grafting, seven limbs had a significantly worsening of the exercise response postoperatively. These findings were not related to the patency of the superficial femoral artery in the donor limb. Deterioration in donor limb hemodynamics noted in 20 (45%) of the 44 patients in this series suggests that strict patient selection criteria should be maintained. Unlike in healthy subjects, an arteriographically patent atherosclerosis iliac artery may not support flow requirements of bilateral lower limb exercise.

Assessment of a modified technique of distal splenorenal shunting.

Warren's distal splenorenal shunt has been effective in treatment of recurrent variceal hemorrhage. To simplify the operative procedure, two alterations in the technique were used in this study. The first was to approach the splenic and renal veins simultaneously through a single inframesocolonic retroperitoneal incision in the plane of the pancreatic fusion fossa. The second was abandonment of the portoazygos disconnection. Since 1974, twenty-nine patients have undergone this modified operation. The patients ranged in age from 21 to 76 years. Fourteen patients had alcoholic cirrhosis, 13 had nonalcoholic cirrhosis, and the etiology was unknown in two. There were 14 Child's class A patients, 12 class B, and three class C. Significant ascites was present at operation in seven patients. Hepatofugal flow was demonstrated angiographically in four patients. The follow-up period ranged from 6 months to 6 years; 19 patients were followed up for 1 year or longer. There were three early postoperative deaths (10.3%), and one patient died 2 months postoperatively. Recurrent variceal bleeding was seen early in one patient and late (2 months) in another. Only one of the surviving patients developed encephalopathy. Technical modification to simplify performance of the distal splenorenal shunt did not compromise the results of the operation. However, four of seven patients with ascites died either immediately or early after the procedure, and two of these four patients also had hepatofugal flow. Ascites and hepatofugal flow may adversely influence the results of the operation.

The effect of partial starvation and glucagon treatment on intestinal villus morphology and cell migration.

Male Sprague-Dawley rats were either treated with repeated ip injections of glucagon every 6 hr or partially starved. After 7 days of partial starvation or 5 days of glucagon injections, a time period shown previously to induce increased transport, all animals were sacrificed and a segment of jejunum was removed, fixed in formalin, sectioned, and dipped in Kodak NTB-2 liquid emulsion. After 8 weeks of exposure the autoradiographs were developed; assessments of villus height and crypt depth and measurements of length of the column of exposed grains were made in a calibrated microscope. The mean villus length in both semistarved and glucagon-treated groups was found to be significantly reduced (p less than 0.001) when compared to control animals. The crypt-to-villus ratio was found to be unaltered by either treatment modality. The rate of cell migration was diminished by both partial starvation and glucagon treatment, but only glucagon therapy was found to cause a significant (p less than 0.01) reduction in the rate of cell movement when compared to controls.

Treatment with glucagon-binding antibodies alters the intestinal response to starvation in the rat.

Everted intestinal rings from partially starved rats accumulate the nonmetabolized amino acid 1-amino-cyclopentane-5-carboxylic acid (ACPC) at an enhanced rate. Plasma glucagon concentrations were found to be markedly elevated in these partially starved rats as well as in rats with experimentally induced diabetes, a condition previously shown to be associated with augmented intestinal uptake of amino acid. Treatment of partially starved rats with repeated injections of glucagon-binding antiserum prevented increased ACPC uptake of intestinal rings. Chronically elevated plasma glucagon levels may participate in the mechanism of the functional changes in the intestine in partial starvation.