Determination of intestinal viability.

Operations for intestinal ischemia are frequently done by veterinarians. In equine surgery those conditions commonly producing ischemia are intussusception, volvulus, bowel obstructions, and incarcerated hernias. In an attempt to predict intraoperative bowel viability after the restoration of circulation, a variety of adjuvant methods have been investigated. There is little question that of the techniques currently available, sodium fluorescein injected intravenously approaches the ideal in predicting nonviability in humans and in most animal models. Furthermore, it is safe, takes little operating time, is inexpensive, and is ubiquitously available; in addition, the only special equipment needed is a long-wave ultraviolet lamp. Reliance on this method would seldom result in nonviable bowel being left in situ. Furthermore, the use of fluorescein would minimize the unnecessary resection of viable intestine and, thereby, minimize the postoperative nutritional problems that may occur, especially in equines. The report of Sullins et al questions the accuracy of the fluorescein technique in predicting viability and nonviability in horses and also raises the question as to whether the prediction of viability, after the restoration of intestinal blood flow, also predicts normal intestinal function. Further investigations will be needed to confirm or refute these observations.

Localization of the parathyroid glands by intraoperative methylene blue staining.

Exploration of the neck for primary hyperparathyroidism has increased in our institution, as evidenced by nine patients treated in the past one year, as compared with six in the previous three years. Our experience indicates that methylene blue staining has served as an important adjunct in the localization of abnormal parathyroid glands. No complications were noted intraoperatively or postoperatively as a result of its use. Operating time was measurably decreased. The results of this study support the routine use of methylene blue in both primary and secondary parathyroid exploration, and this is currently being done in our institution.

The effect of fluid infusions upon serum protein concentrations during hemorrhagic shock.

Of 24 dogs subjected to hemorrhagic shock, 12 resuscitated with intravenous infusions containing 2.5 per cent human serum albumin maintained significantly higher, p less than 0.05, serum albumin levels than did 12 others treated with Ringer's lactate solution, with or without 50 per cent dog plasma. These differences persisted for as long as six weeks after hemorrhage. Dogs resuscitated with Ringer's lactate solution and 50 per cent dog plasma had significantly higher serum globulin levels than did the dogs receiving 2.5 per cent albumin containing infusion during the first three days after hemorrhage. The simultaneous addition of 5 per cent glucose, potassium chloride and hydrocortisone sodium succinate to the infusion of dogs receiving 2.5 per cent albumin in Ringer's lactate solution did not provide significant alterations in the serum concentration of protein and protein fractions when compared with those of dogs receiving only 2.5 per cent albumin in Ringer's lactate solution. These findings corroborate the suggestion of a capillary leak of serum albumin into the interstitial space during hemorrhagic shock that persists for at least one week after hemorrhage. The administration of albumin containing solutions during the initial stages of hemorrhagic shock counteracts this albumin loss.

Survival following infusion of Pitressin into the superior mesenteric artery to control bleeding esophageal varices in cirrhotic patients.

Morbidity and mortality data from patients with bleeding esophagogastric varices treated with portosystemic shunts relate to the clinical status of the patient and to control of hemorrhage both in the immediate postoperative period as well as later. To obtain comparable data following selective infusion of pitressin into the superior mesenteric artery (SMA), records of 23 consecutive patients with cirrhosis, diagnosed by endoscopy as bleeding from varices and treated with SMA pitressin infusions, were reviewed. Twenty-four infusions were performed and hemorrhage was controlled in 12. Fourteen of the 23 patients subsequently underwent portosystemic shunts. Pitressin infusion controlled hemorrhage preoperatively in seven of these, and five survived one year or longer. The remaining seven, in whom bleeding was not controlled by pitressin, died postoperatively. One of the nine patients not undergoing a portosystemic shunt survived more than eight weeks after pitressin infusion. Vascular complications occurred in seven of 17 who died. These complications and the delay between institution of pitressin and operative therapy to control variceal hemorrhage appears to be a factor in the high mortality rate. Portosystemic shunt remains the best therapy for uncontrolled hemorrhage and to prevent recurrent bleeding from esophageal varices.

Pancreatic pseudocyst: management in fifty-four patients.

The management of pancreatic pseudocyst was reassessed in fifty-four patients: only sixteen (30 per cent) regressed with nonoperative management; six (11 per cent) died of septic complications; and thirty-two (64 per cent) eventually required operation. Most pseudocysts did not regress with nonoperative therapy, thus emphasizing the need of serial clinical and ultrasonic examination at frequent intervals to detect nonresolution or complications requiring earlier operation than previously advocated.

Abdominoperineal resection in the treatment of devascularizing rectal injuries.

Local debridement, drainage, and diverting colostomy, with or without primary repair of the rectum, have been considered to be the standard treatment for most rectal injuries, but they are not sufficient for those patients sustaining uncontrollable bleeding or extensive rectal devascularization. This report assessed the indications and results of abdominoperineal resection of the rectum in these patients. Ten patients who were victims of explosive trauma presented with massive perineal injuries and extensive rectal devascularization. Six of these were treated with local debridement of necrotic tissue, pararectal drainage, antibiotics, and colostomy. Five of the six patients initially treated by colostomy died after operation from hemorrhage or sepsis. The sixth patients, who survived, had an abdominal resection of the rectum performed 5 days after the colostomy for removal of a gangrenous rectum. All five of those who underwent abdominoperineal resection survived (p less than 0.01). Increasing violence in the life patterns of modern society enhances the possibility of occurrence of this type of lesion, previously limited to military practice. The need for careful investigation of rectal viability is emphasized. Primary abdominoperineal resection of the rectum is advised when extensive devascularization has occurred.

Detection of anticoagulation therapy failures in patients with venous thrombosis.

Results of ultrasonic monitoring of venous patency and fibrinogen uptake testing were evaluated in ten patients with venous thrombosis receiving heparin therapy. Two propagating venous thromboses were detected 24 to 48 hours before massive pulmonary embolism developed, thus emphasizing the usefulness of these methods for detection of anticoagulation therapy failures.

Primary repair of colonic injuries: a clinical evaluation.

Fifty-seven patients with colonic injuries were treated by primary repair with or without exteriorization. Forty-six of these had other associated major intra-abdominal, intrathoracic, and musculoskeletal injuries. All had minimal contamination of the peritoneal cavity and were operated upon within 6 hours of injury. None showed any evidence of anastomical leakage or breakdown. Minor complications occurred in 12 patients (21%). Two deaths (3.5%) resulted, but neither was attributable to the repair of the colon; one died from renal failure and the other from pulmonary embolism. On the basis of this study, it is concluded that most isolated injuries of the colon resulting from low-velocity bullets and sharp objects can be closed primarily if peritoneal contamination is minimal and antibiotics are administered immediately after injury, during operation, and post-operatively.

Arterial scan versus radiographic angiography in detection of shallow arterial ulcers.

A comparison of 99m-technetium albumin aggregated arterial scan and radiographic angiography for detection of shallow intimal carotid artery ulcerations was made in a series of 12 anesthetized dogs, having a total of 16 acute arterial ulcerations. Radiographic angiography showed positive findings related to presence of stenosis or mural thrombosis in 12 instances. Direct visualization of ulceration was only exceptionally encountered. Arterial scan detected 14 of 16 intimal ulcers. The radionuclide method was reliable even in absence of stenosis or when only minimal mural thrombosis was present. Moreover, autopsy scan of the isolated arterial segments detected all 16 intimal lesions. These results indicate that the arterial scan was a more reliable method for detection of shallow arterial ulcers in this experimental model than radiographic angiography, especially when arterial lumen stenosis or mural thrombosis were minimal or absent.

Penetrating torso injuries: the role of paracentesis and lavage.

Controversy still exists regarding the proper approach to patients with penetrating torso injuries. Mandatory immediate celiotomy and selective observation both have associated risks. Paracentesis with lavage is a rapid, easily performed and readily available technique which can, with a high degree of accuracy, differentiate on initial evaluation those patients with penetrating visceral injuries from those without such injuries. Complications are minimal. The use of these two procedures in evaluating penetrating torso injuries has led to improved patient care and produced major lowering of medical and socioeconomic costs.

Serum protein concentration during hemorrhagic shock.

Early changes in serum protein concentration during hemorrhagic shock were evaluated in a series of 20 dogs, following massive bleeding. The serum protein concentration fell faster than did the hematocrit value, with significant changes becoming apparent 15 minutes after hemorrhage, p less than 0.05. After this initial fall, a less marked descent occurred. The most remarkable changes were in the serum albumin fraction. Changes of the globulin levels were less evident. These findings of an early albumin loss, occurring within 15 minutes following acute massive hemorrhage in the dog, probably are due to a leakage of albumin into the interstitial space, secondary to increased capillary membrane permeability. Larger molecules, such as the globulin fraction, did not consistently decrease during the first 45 minutes following shock, a possible indication that loss of this protein into the interstitial space did not occur in a consistent manner. The aforementioned findings support the early use of intravenous infusions containing macromolecules, larger than albumin, during hemorrhagic shock, to re-establish an oncotic gradient, which is diminished due to a loss of albumin from the circulation.

Hepatobiliary scanning using 99mTc-pyridoxylideneglutamate.

Technetium 99m-pyridoxylideneglutamate (99mTc-PG) administered intravenously is excreted by hepatocytes into the bile canaliculi and enters the gallbladder through the cystic duct and consequently, can be used for scanning the hepatobiliary ductal system. A total of 166 patients representing 27 normal subjects, 84 patients referred for investigation for pain in the upper right quadrant of the abdomen and 55 jaundiced patients were evaluated with 99mTc-PG. In normal human volunteers, the agent reached the liver in five minutes, and the common bile duct, gallbladder, and duodenum within 15 minutes. Satisfactory images of the hepatobiliary tract were obtained using small dosages of 99mTc-PG. The gallbladder was not visualized when the cystic duct was occluded. In the presence of acute cholecystitis, cystic duct obstruction, or in chronic cholecystitis where other roentgenographic studies showd a nonfunctioning gallbladder, there was no concentration of 99mTc-PG in the gallbladder. In partial common bile duct obstruction is distended common bile duct was visualized along with delay in transit of radioactivity into the duodenum. Complete common bile duct obstruction was associatedwith no radioactivity in either the biliary or the gastrointestinal tracts up to 24 hours after injection. Hepatocellular disease was characterized by delayed liver clearance and delayed visualization of biliary and gastrointestinal tracts. 99mTc-PG scanning proved capable of differentiating between hepatocellular disease and extrahepatic biliary tract obstruction.

Technetium-99m pyridoxylideneglutamate (P.G.) cholescintigraphy.

Technetium-99m P.G. cholescintigraphy was performed in 27 human volunteers and 81 patients referred for hepatobiliary tract disease. The gallbladder, biliary system, and gastrointestinal tract were well visualized in the normal patients and volunteers. The gallbladder was not visualized in 22 patients with histologically proved cholecystitis with cystic duct obstruction. Nine patients with complet extrahepatic obstruction of the common bile duct were correctly diagnosed. Hepatocellular disease and incomplete obstruction, with and without jaundice, were diagnosed with this technique. Oral cholecystography is superior to this method for the detection of cholelithiasis in nonjaundiced patients.